














































■ 



















Infant Feeding 

A Handbook for the 
Practitioner 


JULIUS H. HESS, M.D. 

Professor and Head of the Department of Pediatrics, University of 
Illinois, College of Medicine; Chief of Pediatric 
Staff, Cook County Hospital 


1923 



AMERICAN MEDICAL ASSOCIATION 
535 North Dearborn Street Chicago, Illinois 








Copyright, 1923 

American Medical Association 
Chicago 


© Cl A711722 

AuG -7 023 

Am ! 


PREFACE 


This series of articles, somewhat elaborated for 
book form, appeared in the Journal of the American 
Medical Association from January to May, 1923. The 
interest they aroused and numerous requests for pub¬ 
lication in book form, have prompted the issuing of 
this volume. 




CONTENTS 


CHAPTER p AGE 

1. Breast Milk Feeding. 7 

2. Maternal Nursing. 12 

3. Conditions Temporarily Affecting the Quantity and 

Quality of Breast Milk. 18 

4. The Nursing Proper. 23 

5. Mixed Feeding and Weaning. 31 

6. The Physician. 35 

7. Underfeeding . 38 

8. Overfeeding . 42 

9. Intercurrent Parenteral and Enteral Infections_ 47 

10. Idiosyncrasy Toward Mother’s Milk. 49 

11. Care and Feeding of Premature Infants. 51 

12. The Artificial Feeding of Infants. 64 

13. Cow’s Milk and Goat’s Milk. 73 

14. Clinical Aspects of Infant Feeding. 88 

15. Estimating the Amounts of Individual Food Ele¬ 

ments . 94 

16. Summary of Quantitative and Caloric Relationship 

of the Food Constituents. 105 

17. Principles Governing the Preparation of Milk 

Mixtures . Ill 

18. Feeding During Different Periods of First Year.. 127 

19. Feeding After First Year. 135 

20. Facts to Be Considered in Formulating Diet. 140 

21. Suggested Average Diets from Six Months to Six 

Years, Inclusive. 143 




























Fig. 1.—Proper method of holding baby during nursing. The nurse 
is seated on a low nursing chair with her right foot elevated on a low 
stool. 








CHAPTER I 


BREAST MILK FEEDING 

From every standpoint, the ideal mother is one who 
can nurse her own baby, and thereby furnish it with 
sufficient milk to meet its needs for normal growth and 
development. The mother who is not anxious to nurse 
her infant is a great exception. In fact, most women 
are greatly disappointed at being unable to meet the 
full requirements of their baby. 

The mother can easily be impressed with the fact 
that breast milk is the ideal food for a baby. It is 
always fresh; with a simple technic it remains clean, 
and it is always available. From the standpoint of 
economy, it is by far less expensive than other foods. 
It is the best prophylactic against the communicable 
diseases and the commoner infections in infancy, and 
as a curative measure in the presence of nutritional 
disturbances and infections it has no peer. 

Even more important is the fact that the infant is 
assured a mother’s careful observation, owing to its 
frequent and intimate contact with her. She soon 
learns to recognize the earliest manifestations of its 
illnesses. It must be recognized as a fact that most 
mothers are capable of nursing their infants. 

It cannot be denied that there are mothers whose 
mental and physical condition makes breast feeding 
inadvisable, but fortunately they are greatly in the 
minority. Breasts with an insufficiency of glandular 
tissue to meet the full needs of the infant, even during 
the first months of lactation, are encountered more 
frequently. Far less commonly do we find breasts so 
poorly developed that all lactation is to be disregarded. 

McClanahan, 1 summarizing the opinion of a group 
of pediatricians whom he interrogated for opinions 


1. McClanahan, H. M.: Arch. Pediat. 35: 653 (Nov.) 1918. 




8 


BREAST MILK FEEDING 


as to the relative morbidity among breast and bottle fed 
infants, concluded: 

Breast-fed infants are less susceptible to infection, with 
possibly two exceptions—influenza and tuberculosis. They 
resist infection to better advantage and with less after-effect 
from the disease. Breast-fed infants have less morbidity 
than properly fed bottle infants, and the advantages are still 
greater as compared with infants who have been improperly 
fed. 

Studies made in many different countries have 
demonstrated that the death rate among the artificially 
fed is at all times higher than among the breast fed; 
that when breast feeding is the custom, the mortality 
rate is low in spite of other unfavorable factors; and 
that when breast feeding is increased in a community, 
the infant mortality rate is lowered. 

In studies made in overcrowded and poverty-stricken 
districts of London, New York, Chicago and other 
large cities, the fact is very clearly brought out that 
where by race or custom it is the practice to feed infants 
at the breast, the infant mortality rate is lower, even 
though the environment is highly insanitary. 

In our complicated modern society, there must be 
widespread emphasis among all classes, not only on 
the importance of breast feeding but also on the ways 
and means of making it successful. There are many 
false opinions to be overcome, such as the statement 
frequently made that the modern woman has lost the 
ability to suckle her young, and the feeling created, as 
a result of the emphasis on the importance of pure 
milk and pasteurization in infant feeding, that this 
is at least as good as breast feeding and often better. 

The reports of Sedgwick 2 of the findings of the 
Breast Feeding Investigation Bureau of the University 
of Minnesota confirm the ideas which many physicians 

2. Sedgwick, T. P.: Preliminary Report of Study of Breast Feeding 
in Minneapolis, Am. J. Dis. Child. 21 : 455 (May) 1921. 



STIMULATION OF BREASTS 


9 


have held, that in greater part the inability of the 
mother to nurse her infant is due to improper instruc¬ 
tion and insufficient encouragement on the part of the 
attending obstetrician and those responsible for her 
nursing care. 

Only too frequently when the question is asked, 
“Why did you wean your child?” the answer is, 
“Because the doctor advised me to do so.” Knowing 
how commonly this is true, there is certainly room for 
missionary work in order that breast feeding may 
receive further encouragement. 

The University of Minnesota breast feeding bureau super¬ 
vised the care of 2,847 babies during the year 1919. Of these, 
96 per cent, were at the breast at the end of their second 
month, and of 2,022 still under observation at the end on 
nine months, 72 per cent, were at the breast receiving part 
or all of their food in this way. 

In Boston, the Baby Hygiene Association has had such 
success, that of 6,000 infants under its supervision only 196 
babies less than 6 months old were entirely artificially fed. 
The statistics of the Starr Center in Philadelphia are equally 
notable. In 1912-1913, only 48 per cent, of the babies under 
its care were breast fed. After six years of propaganda for 
breast feeding, of ninety-two infants whose mothers had been 
cared for by the prenatal department, ninety were entirely 
breast-fed at 1 month of age, one was partially breast-fed, 
and only one was bottle fed. 

STIMULATION OF THE BREASTS 

The demand which is made on the breast is by far 
the most important factor in the maintenance of the 
breast milk supply. Repeated, regular and complete 
evacuation of the breasts by a vigorous baby is, of 
course, the natural and best method. When this natu¬ 
ral stimulus is not obtained, or when the demand on 
the breast 'is insufficient for any reason, the supply of 
breast milk decreases gradually until the supply is 
insufficient to meet the infant’s needs. In these cases, 
artificial aid is necessary. 


10 


BREAST MILK FEEDING 


HAND EXPRESSION 

Expression by hand is the best method for stimu¬ 
lating the breasts to secrete, when an infant is not 
available for this purpose. Wetnurses find it of the 
greatest advantage to practice expression at regular 
four hour periods, and when the breast is practically 
drained to place the wetnurse’s infant at the breasts to 
empty them completely, both breasts being emptied at 
each period. The following methods for breast expres¬ 
sion may well be followed: 

The hands and nails should be scrubbed with soap, warm 
water and a nail brush, for at least one full minute. The 
nipple is washed with fresh absorbent cotton and boiled 
water or a boric solution. The hands are dried thoroughly 
on a clean towel and kept dry. A sterilized graduated glass 
tumbler or large-mouth bottle should be at hand to receive 
the milk. 

1. The breast is grasped gently, but firmly, between the 
thumb placed in front, and the remainder of the fingers on 
the under surface of the breast. The thumb in front and 
the first finger beneath should rest just outside the pig¬ 
mented area of the breast. 

2. With the thumb, a downward pressing motion is made 
on the front against the fingers on the back of the breast, 
and the thumb in front and fingers behind are carried down¬ 
ward to the base of the nipple. 

3. This second act should end with a slight forward pull 
with gentle pressure at the back of the nipple, which causes 
the milk to flow out. 

The combination of these three movements may be described 
as “back, down, out.” 

It is not necessary to touch the nipple. 

This act can be repeated from thirty to sixty times a 
minute after some practice. 

It is advisable to empty both breasts at each expression 

The milk should be covered at once by a sterile cloth held 
in place by a rubber band and kept on ice until used. 

Hoobler 3 reports that in the city of Detroit during 
two succeeding years, 67,000 ounces and 60,000 ounces, 

3. Hoobler, B. R.: Tr. Am. Ped. Soc. 32: 290, 1920. 




Fig. 2.—Direct expression of milk, first stage. 
















Fig. 3.—Direct expression of milk, last stage 













HAND EXPRESSION 


11 


respectively, of milk was expressed from the breasts of 
women in different institutions and from private 
sources, and distributed throughout the city. Contin¬ 
ued stimulation of the breasts by expression of the milk 
resulted in increasing quantities of milk. 

Understimulation of the breasts results in a deficient 
milk supply. 


CHAPTER II 


MATERNAL NURSING 

The Diet of the Mother .—The first principle of feed¬ 
ing a nursing mother should be to provide her with 
an abundance of simple but nourishing food. It should 
always be palatable and to the mother’s liking. During 
the first days following labor and while she is still in 
bed, she should be on a more or less light diet, but 
one that is varied so that her appetite may be stimu¬ 
lated ; she may thereby be encouraged to take sufficient 
food to meet the needs of the infant and herself. Four 
meals in twenty-four hours are usually all that she will 
take with comfort, while in bed. 

When the mother is up and about, and has resumed 
her ordinary duties, she may be allowed to eat such 
foods as she was accustomed to before the advent of 
pregnancy and motherhood. It is a fallacy to forbid 
vegetables and fruits on general principles. As a 
rule, food that the patient can digest without incon¬ 
venience is a safe food, so far as the nursing is con¬ 
cerned. Occasionally an infant is seen who reacts to 
mother’s milk by the development of colic when certain 
of the aromatic vegetables, such as turnips, cauliflower 
and onions, are a part of the mother’s diet. Or, again, 
the same foods, or such additions to the mother’s diet as 
coffee or salads, may interfere with her digestion and 
thereby change the quantity and not infrequently 
also the quality of her milk, all of which may 
react upon the child. Exceptionally an infant is seen 
that has become sensitized to one of the animal or 
vegetable proteins. These cases will be more fully 
discussed under “Idiosyncrasy to Mother’s Milk.” 
Restrictions in the mother’s diet are, however, more 
especially indicated when she is feeding a premature or 


DIET OF THE MOTHER 


13 


sick infant, because such infants are more readily 
affected by qualitative changes in the breast milk. More 
commonly, the error in the mother’s diet lies in the 
nature of underfeeding and overfeeding. A greatly 
restricted diet in a robust young mother who has always 
eaten to her own satisfaction of a generous variety of 
foods is one of the surest means of curtailing the 
quantity and lowering the quality of her milk supply. 
On the other hand, overfeeding leads to revulsion to 
food, and sooner or later indigestion results. When the 
mother is convinced that any article of food disagrees 
with her, even though there may be doubt about it, the 
food should be discontinued. In a general way, milk, 
eggs, meat, fish, poultry, cereals, fresh vegetables and 
fruits should constitute the basis for selection. The 
acid fruits, salads and aromatic vegetables may be tried, 
to be discarded if they seem to distress the infant. 
Eggnogs, cereal gruels with milk, cocoa with milk, 
malted milk, and similar drinks can be given with the 
meals; or, when the mother desires, she may take them 
between meals. The day’s diet should include 1 quart 
of milk in some form, and at least 1 quart of water. 
Tea and coffee in moderate amounts may be permitted. 

Number of Meals .—Most mothers are better satisfied 
when eating only four times daily, the fourth meal 
being supplied at bedtime. The latter should consist 
of a dish of cereal and milk, or some other simple and 
easily digested food. 

Air and Exercise .—From two to four hours daily 
should be spent in the open air, weather permitting. 
During this outdoor period, she should take moderate 
exercise, but never to the point of fatigue. It is well 
to divide the time of recreation into a morning and an 
afternoon period. 

Sleep .—At least eight hours out of every twenty-four 
should be given to sleep. If her nights are disturbed, 


14 


MATERNAL NURSING 


she should have the benefit of an hour or two rest 
period during midday. In case the infant has been 
accustomed to a feeding during the night, this should 
be withdrawn as soon as possible so that there will 
be only one nursing period between 6 p. m. and 6 a. m. 
This is most easily accomplished when the infant sleeps 
in a room separated from the mother and is under 
another’s care during the night. Under all circum¬ 
stances, the infant must sleep in its own crib. 

To Avoid Constipation .—One free evacuation daily 
should be insisted on. As the excessive use of 
cathartics may result in diarrhea in the baby, efforts 
should be made to regulate the bowel function through 
food and exercise. A glass of cold water on arising 
in the morning, combined with a diet containing coarse 
cereals, sufficient vegetables and fruits, is usually all 
that is necessary. If this regimen does not have the 
desired effect, abdominal massage and local measures, 
such as an oil enema or a suppository, may prove effec¬ 
tive. When these measures do not prove effective, 
it may be necessary to administer mild laxatives, such 
as liquid petrolatum, magma magnesiae or cascara 
sagrada. If no evacuation of the bowels has taken 
place during the previous twenty-four hours, an enema 
should be administered at bedtime. 

Care of the Breasts .—During the latter months of 
pregnancy, a small amount of clear fluid is secreted by 
the breasts. Toward the end of pregnancy, and for 
the first few days after labor, colostrum is secreted. By 
the third or fourth day the character of the secretion 
is changed so that it resembles the later milk in both 
its physical and its chemical properties. The specific 
factor or factors which stimulate milk secretion are as 
yet unknown, but it is not unlikely that it may be in 
the nature of an enzyme. Two important results follow 
continued stimulation of the breasts by the infant: (1) 



Fig. 4.—Breast tray and its contents: tray, boric solution, liquid petro¬ 
latum, gauze in jar, cotton in jar, glass, applicators in jar. 



















































CARE OF THE BREASTS 


15 


contraction and involution of the uterus, and (2) 
increased secretion of breast milk. In the average 
breast, feeble stimulation results in a minimal milk 
supply, while stimulation by a strong infant or regular 
expression will be followed by a supply varying directly 
with the demand made on the breasts. 

In the presence of small nipples, slight traction night 
and morning during the last months of pregnancy has 
a beneficial effect in lengthening the nipple. 

A well established routine should be instituted for 
the care of the breasts during the period of lactation. 
To facilitate this, a readily accessible tray with the 
necessary utensils should be provided. This should 
contain a glass-stoppered bottle with a saturated solu¬ 
tion of boric acid, a jar of cotton pledgets on tooth¬ 
picks, to be used as applicators for the boric acid, and 
a graduated glass or beaker. The nipples should be 
thoroughly washed before and after nursing with a 
saturated solution of boric acid poured fresh from the 
bottle for each cleansing, and the surplus thrown away. 
The boric acid should be applied with the cotton 
pledgets. The fingers should not come in contact with 
the nipples, if the child is to nurse directly at the breast. 
If the nipples are tender, they should be anointed with 
a sterile mixture of 5 per cent, tincture of benzoin in 
liquid petrolatum. 

In some cases, when the milk first comes in, the 
breasts may become engorged and painful. Usually 
this rights itself without difficulty as soon as the rela¬ 
tion between the supply and demand is established. 
During this period of adjustment, besides limiting the 
fluids taken, the discomfort from engorgement may be 
relieved by elevating the breasts and keeping them 
partially under pressure by the use of a supporting 
breast binder. If a binder is used in time and the 
mother takes little fluid in her diet for a few days, it is 
rarely necessary to empty the breast by expression or 


16 


MATERNAL NURSING 


with a breast pump. If left alone, mild cases of caked 
breast will disappear without treatment. Unnecessary 
handling of the breasts should be avoided. Besides 
limiting the fluid intake, laxatives are indicated. The 
vegetable cathartics are less likely to pass into the 
milk than are the salines. An icebag applied externally 
to a thin binder often will be of assistance. If the 
cold application produces discomfort, as occasionally 
it does, hot boric dressings protected by oiled silk may 
be used. These should be repeated at hourly intervals. 
The infant should be put to the breast regularly. 

Fissures .—These offer serious difficulties to nursing 
because of pain and the danger of mastitis. Nursing 
through a nipple shield should be tried in order to 
minimize the danger of infection. When the infant 
cannot or will not use the shield, expression should be 
practiced. Failure to empty the breasts by these 
methods may make it necessary to risk the danger of 
infecting the breasts by allowing the infant to nurse 
directly from the breasts. When a nipple shield is 
used, it is imperative that it be cleaned thoroughly after 
nursing and reboiled before using. Among the best 
local applications are silver nitrate solution, 5 per cent., 
followed by an ointment, such as balsam of Peru, 1 
part, and castor oil, 30 parts; or silver nitrate, 1 part, 
balsam of Peru, 2 parts, and sufficient petrolatum to 
make 30 parts. 

Mastitis .—This is of frequent occurrence, even dur¬ 
ing the week following delivery, manifesting itself by 
headache and circumscribed pains in the mammary 
gland. The disease is usually confined to one of the 
lower quadrants. Tenderness, swelling, surface red¬ 
dening and hard nodular points follow. The course 
of these mastitides, most of them parenchymatous, is 
favorable. 

Much more serious are those cases which occur 
later, usually about three weeks after delivery. They 


MASTITIS 


17 


begin more violently, with high fever, headache, vomit¬ 
ing, reddening of the skin and tumor formation which 
is painful to pressure. The pain is exhibited both at 
the seat of the trouble and in the axilla. With 
improper treatment, abscess formation quickly occurs 
and is often followed by repetitional relapses. In these 
cases we have often to deal with an interstitial mastitis. 

Great care should be taken in differentiating between 
a simple engorgement (caked breast) and mastitis. 
As in the former, there is every indication for keeping 
the child at the breasts, in order that they may be 
emptied at regular intervals. Further indications for 
treatment in caked breast are met by a dry diet and 
purgation. When a diagnosis of mastitis is established, 
the infant should be removed from the breast and a 
tight binder applied. Two large icebags should be 
applied to each breast, kept half full so that they may 
not be too heavy. The binder should be thin, so that 
the icebags are not separated from the skin by enough 
cloth to prevent the cold from reaching the gland. The 
skin must feel cold to the touch; otherwise, no good 
will be derived from the ice. A saline cathartic may 
be given, and the liquids in the diet are restricted. 
The icebags may be removed one at a time after the 
patient has had a normal temperature for twelve hours. 
The infant is put back to the breast twenty-four hours 
after the temperature becomes normal. 

If an abscess develops, the pus should be evacuated 
through radiating incisions. Even in the presence of 
abscess formations it is only exceptionally necessary to 
wean the infant. Usually by the end of the first week, 
even though the wound is still open and draining, the 
infant can be returned to the breast, after the first 
milk at each nursing is expressed and discarded. This 
will be found to have a favorable influence on healing. 
In most cases the breast function is soon reestablished. 


CHAPTER III 


CONDITIONS TEMPORARILY AFFECTING THE 
QUANTITY AND QUALITY OF 
BREAST MILK 

In many women the return of the menstrual period 
is associated with changes in the breast milk. This is 
especially true of the first menstrual period. In some 
instances they may occur with each menstruation. 
They may be both quantitative and qualitative. In 
cases of simple reduction in the food, the infant will 
frequently show signs of hunger. At other times, 
when there are also qualitative changes, colic and 
indigestion, the latter associated with frequent stools, 
occurs. 

Menstruation is never an indication for weaning, 
and only rarely should any of the feedings be discon¬ 
tinued at these times, even though they cause minor 
disturbances in the infant. Disturbances are most 
frequently seen either before or during the first 
menstrual period. 

The mental condition of the mother may have a 
direct influence on the milk, secretion. These changes 
are, however, usually only temporary. When the 
infant is distressed at these times, it may be wise 
temporarily to remove it from the breast for one or two 
days, until the mother has recovered from the under¬ 
lying cause, such as grief, shock, fright or anxiety. 
Expression should be practiced in the interim. 

Drugs .—Alkaloids of opium, hyoscyamus, belladonna 
and similar drugs not infrequently pass into the milk 
and should therefore never be administered in large 
quantities to the nursing mother. Belladonna may 
cause a decrease in milk secretion and should be admin¬ 
istered with caution during the period of lactation. 


CONTRAINDICATIONS TO NURSING 


19 


Mercury, iodids and the newer salts of arsenic are also 
secreted in the milk and may be used to advantage 
when a syphilitic mother is nursing her infant. 

Contraindications to Nursing. —Tuberculosis, when 
progressive or open, is always a contraindication to 
nursing, because of the danger to the infant and the 
strain on the mother. With proper precautions, and 
when the breast is not diseased and human milk is not 
obtainable from other sources, it may be well to tide 
a weak infant over its first weeks by expressing the 
milk from the mother’s breasts. It must be boiled 
before it is used. 

Syphilis of the mother, except in freedom from 
infection on the part of the infant, is not a contra¬ 
indication. Lack of the symptoms on the part of the 
mother in congenital syphilis is a very common occur¬ 
rence ; a Wassermann reaction on the mother’s blood 
will usually clear up any doubt. 

Any grave constitutional disease in which there is 
an extraordinary drain on the resources of the body, 
such as diabetes, heart disease with disturbed compen¬ 
sation, nephritis, exophthalmic goiter, malignant neo¬ 
plasms, epilepsy and psyphoses are contraindications 
to nursing. * 

Acute diseases should only in exceptional cases be 
considered as contraindications to nursing. Only con¬ 
ditions in which there is danger of overburdening the 
mother and infecting the infant should lead to its 
removal from the breast. 

In acute infections in the mother, such as pneu¬ 
monia, and the acute contagious diseases, such as scar¬ 
let fever, after considering the condition of the mother, 
one must weigh the danger from exposure to infection 
of the infant, as against the quality of the artificial 
food and environment in the individual case. 


20 CONDITIONS AFFECTING BREAST MILK 


In the milder contagious diseases, such as measles 
or mumps, it is true that young breast-fed infants are 
rarely infected. Pertussis is an exception and has a 
high mortality in the new-born and young infants, and 
the infant should under all circumstances be protected 
from exposure. In the presence of diphtheria, the 
infant can be immunized with safety. 

Pregnancy .—Only under exceptional circumstances, 
such as congenital weakness or illness on the part of 
the infant, should a mother be called on to prolong 
lactation after she becomes aware of her condition. 
First, she should not be called on to undergo the strain 
of nourishing her infant, the fetus and herself. Sec¬ 
ondly, conception rarely occurs during the first months 
of lactation, the infant thereby having had the benefit 
of a good start on the breast, and bottle feeding can 
usually be instituted without great danger. 

EXAMINATION OF HUMAN MILK 

No baby should be deprived of its mother's milk 
because of the results obtained on chemical analysis. 
The baby, and not the laboratory, offers the practical 
test for judging the quality of breast milk. It is well 
known that the composition of milk, more especially 
in its fat and to a lesser degree in its protein and sugar 
content, varies greatly in the same individual, not only 
from day to day, but also at different periods of the 
same nursing. An analysis, therefore, to be of value, 
should be made from a specimen obtained from several 
expressions during the twenty-four hours, and each 
specimen should consist of the milk of an entire 
expression or the middle portion. The latter can be 
accomplished by allowing the infant to nurse for two 
or three minutes before the sample is expressed. A 
safer method would be to collect samples at all of the 
regular nursing periods. It is also essential for any 


COMPOSITION OF BREAST MILK 


21 


conclusion that the total amount of the milk obtained 
in twenty-four hours be known through weighing the 
baby before and after each feeding. It is also to be 
remembered that the quality of the milk cannot be 
gaged by simple chemical analysis, because of the 
impossibility of estimating some of its most vital 
contents. Repeated examination of the milk from 
different wetnurses secreting about the same average 
quantities has shown marked variations in the chemical 
composition, notwithstanding which fact the infants 
under observation made equally good progress on the 
different milks. Again, normal chemical averages may 
be found in milk lacking essentials for the proper 
growth of the infant. 


Table 1 . — Composition of Mature Breast Milk 


Reaction. 

Specific gravity 

Fat . 

Sugar . 

Protein . 

Salts . 

Water . 


Amphoteric or alkaline 
..From 1.010 to 1.040 
...3.0 to 4.0 per cent. 
....6.0 to 7.0 per cent. 
. ... 1.5 to 2.0 per cent. 

.0.2 per cent. 

. .86.0 to 88.0 per cent. 


The average composition of mature breast milk 
approximates the figures given in Table 1. 

On the addition of rennin it clots in fine curds. 
Oppenheimer 4 says: 

In general, variations in quality determined by analysis 
fall into three types: 

1. All elements too high: This type is most frequently 
found in women who do too little and eat too much and too 
rich food. 

2. Fat and sugar low, proteins high: This type is usually 
found in women of the poorer classes who are overworked 
and underfed. 

4. Oppenheimer, E.: Pub. 83, Breast Feeding Children’s Bureau, 
Washington, D. C. 














22 CONDITIONS AFFECTING BREAST MILK 


3. Fat and sugar very low, proteins very high: This type 
is usually found in the highly strung, overeducated and 
highly civilized women of the larger cities, but may be 
found in neurotic women of any class or community. 

In recent years variations in the nutritional proper¬ 
ties of human milk have been shown to be due to its 
vitamin content. The vitamins of human milk are 
supplied from the food taken by the mother; if they 
are not present in sufficient quantities in her food, the 
milk suffers. The effect of an insufficient amount or 
absence of these substances is exhibited in the child. 
Scurvy, for example, in the breast fed has been shown 
to develop because of the deficiency of the antiscorbutic 
factor in the mother’s food. The development of 
rickets in the breast fed has also been shown to be due 
to a deficiency in the mother’s diet, reflected in the 
quality of her milk. 


CHAPER IV 


THE NURSING PROPER 

Regularity in Nursing .—The breast that is emptied 
at definite intervals invariably functions better than 
does one which is not, as regards not only the quantity, 
but also the quality of the milk. Thus, regular habits 
in breast feeding are as essential to milk production 
as to its digestion and assimilation. The baby should 
be wakened to be fed. 

The average mother will supply the needs of the 
individual meal with one breast, and the breasts 
should be alternated in successive feedings. Thorough 
emptying of the breast should be encouraged under 
all circumstances, as this is our best method for 
increasing the milk supply, and the baby is the only 
means at hand by which this can be accomplished. 
This should be encouraged in every instance. It is 
most readily thwarted by allowing a lazy baby partially 
to empty both breasts, as this will soon lead to a dimin¬ 
ished milk secretion. 

Sometimes, however, it is advisable to give both 
breasts at each feeding, e. g., (1) during the first few 
days to stimulate secretion, and a little later to relieve 
the congested breasts; (2) to weak babies when there 
is an abundance of milk and they are not strong enough 
to get the last milk, which comes harder; this is to be 
followed by expression; (3) to overfed babies, when it 
is desirable to give them only the first and weakest 
milk and to lessen the yield of milk from the breast; 
(4) as the milk supplied by one breast fails to meet the 
needs of the infant. The first breast should be thor¬ 
oughly emptied before the baby is allowed to take the 
second breast and the next nursing started on the 
second breast given in the last feeding. 


24 


NURSING 


Number of Feedings in Twenty-four Flours .—Four- 
hour intervals should be observed at the outset, with 
either five or six feedings in twenty-four hours, accord¬ 
ing to the individual needs of the child. Night nursing 
can often be discontinued by the second month, and 
babies properly fed will go from 10 p. m. to 6 a. m. 
without anything but perhaps a drink of water. 

A three-hour nursing period is more especially indi¬ 
cated when the mother’s breasts are small and poorly 
developed, as the more frequent stimulation will result 
in a larger twenty-four hour quantity. The same is 
true of a small and weak infant who finds it difficult 
to remain at the breast through the entire nursing 
period. 

Length of Nursing .—As a rule, a robust baby takes 
three fourths of the milk obtained from a good breast 
in the first five minutes of a twenty-minute nursing. 
From fifteen to twenty minutes should be the limit 
for the nursing period. 

The quantity received at individual nursings will 
vary greatly throughout the day. The early morning 
nursings will often yield twice the amount of the later 
nursings. Therefore it is necessary to ascertain the 
twenty-four hour quantity in order to estimate the 
total value of milk received. 

When one breast does not meet the infant’s demands, 
both breasts should be given at each feeding, the nor¬ 
mal nursing time of fifteen or twenty minutes being 
divided between the two breasts, either equally or by 
alternating a long and short feeding period of fifteen 
and five minutes, so that each breast will receive a 
long nursing period at alternate feedings. Weak and 
lazy babies may require awakening during the nursing 
period to keep them at work. Very weak babies may 
require a longer period, with short intervals in which 
they rest. 


AMOUNT OF MILK REQUIRED 


25 


The Daily Total of Milk Required .—Most young 
infants will satisfy their requirements for growth and 
development when receiving an average of 2% ounces 
(75 c.c.) of human milk for each pound (0.45 kg.) 
of body weight in twenty-four hours. Roughly, this 
may be stated as one sixth of the body weight in milk 
daily (50 calories for each pound). Older infants will 
usually thrive on 2 ounces (60 c.c.), or 42 calories of 
breast milk for each pound, or one eighth of their 
weight. 

While infants of the same weight and age under the 
same conditions will require virtually the same amounts 
to provide for growth and development, on the whole 
the fat baby will require less for each pound than the 
thin one. 

Heubner thus expresses the needs of breast-fed 
infants in terms of energy quotient: 

During the first few months, an infant requires 100 calories 
per kilogram daily of breast milk; after the sixth month the 
energy quotient gradually comes down to 80 or 85 at the end 
of the first year. An energy quotient of 70 is the minimum 
amount that an infant can take without losing weight. 

Human milk can be estimated at 21 calories for 
each ounce, or about 70 calories for each hundred 
cubic centimeters of milk. With these figures in 
mind, it is easy to determine whether a breast-fed 
infant gets the right amount of food. It may well be 
emphasized that the infant who is making a normal 
gain should ofifer little cause for anxiety as to the 
exact quantity it may be receiving from day to day. 

Water Requirements .—When the infant is receiving 
one sixth of its body weight in milk during the day, 
little if any additional water is required. When the 
breast milk does not meet this requirement, additional 
water and other food must be administered to meet the 
required one sixth of the body weight in fluids. Dur- 


26 


NURSING 


ing the first days of life, when the breast milk supply 
is insufficient, total fluids should be administered to 
meet the needs mentioned above. From 1 to 3 ounces 
(30 to 90 c.c.) of a 2 to 5 per cent, solution of sucrose 
or lactose which has been boiled may be given to the 
infant at four hour intervals until the milk appears. 

Before the water is given, the infant should be 
placed at the breast at each feeding. Even when milk 
is plentiful, the administration of water two or three 
times daily from a nursing bottle accustoms the infant 
to taking the food in this way. An infant so trained 
will meet emergencies of weaning more readily than 
one unaccustomed to bottle feeding. 

Feeding Daring the First Days .—During the first 
day of life, food may be withheld for twelve hours, 
the infant being kept in a warm crib. It usually soon 
falls asleep, and as a rule it should be awakened only 
to change diapers. As a rule, the child does not 
evidence its initial sensation of hunger by crying until 
after its first half day of life; and even then, in many 
cases, it is difficult to obtain the cooperation of the 
infant in administering its food. During the second 
twelve hours the infant may be put to the breast two 
or three times in order to stimulate secretion and to 
teach it to nurse. During the second twenty-four 
hours the baby should be put to the breast at reg¬ 
ular four-hour intervals. The sixth feeding may be 
omitted. By the third or fourth day the infant will 
usually receive most of its required food from the 
breast. If a night feeding is to be instituted, it is 
well to waken the baby at the regular hour in order 
to cultivate regular habits, which are so essential to 
the mother’s welfare. The infant should at all times 
be taught to take food by the clock. This means that 
it should not be nursed before the accustomed hour 
nor should its feedings be delayed beyond its regular 


INITIAL LOSS OF WEIGHT 


27 


time unless an emergency arises. When the infant 
either cannot take or does not receive sufficient food 
on the four-hour nursing period, with five or six nurs¬ 
ings in the day, it should be put on a three-hour period, 
with seven feedings in twenty-four hours. The aver¬ 
age infant can be trained by the second month to wait 
regularly for its food; and if the milk is of proper 
quality and of sufficient quantity it will sleep quietly 
for most of the interval between nursings. 

Initial Weight Loss .—An initial weight loss is physi¬ 
ologic, and in the main is due to the loss of water 
through the skin, lungs and kidneys, and the meconium, 
by way of the intestinal tract. Necessarily, the weight 
loss is directly influenced by the amount of fluids 
ingested. To a certain extent the weight decrease 
depends on the size of the child, the weight loss, on 
the whole, being greater in a large infant than in a 
small one. The decrease usually continues for from 
two to five days after birth. The average weight loss 
will range between 8 and 10 per cent, of the body 
weight. Losses above the latter figure should always 
lead to careful study of the milk supply and water 
intake, and usually indicate a necessity for comple- 
mental feedings of carbohydrate solutions alone, if the 
breasts seem of good quality, or of milk mixtures. 
Schick 5 has found that he can prevent most of this 
initial weight loss by the feeding of sugar solutions 
during these first days, giving as high as 1 ounce 
(30 gm.) of sucrose during the twenty-four hours. 
Herman reduced initial weight losses one half in a 
study of 200 new-born infants by feeding 1% ounces 
of a 10 per cent, solution of lactose every 3 hours. 
More recently it has been found practical to use a 
5 or 10 per cent, solution of corn syrup as comple- 


5. Schick: Ztschr. f. Kinderh. 27 : 57, 1920. 



28 


NURSING 


mental feeding, the total day’s feeding, including the 
breast milk, averaging one sixth of the infant’s body 
weight. 

The Total Nursing Period .—Some mothers will be 
able to carry on the nursing for only two or three 
months; others as long as nine months. In outpatient 
as well as in private practice it is exceptional to find 
a breast milk supply which is sufficient for the infant 
after the ninth month. It is usually wise to allow one 
bottle feeding daily by the end of the third or fourth 
month in order to relieve the mother and at the same 
time train the baby in bottle feeding. 

Protracted Nursing .—Weaning may be delayed 
when the infant is passing through the hot months of 
summer and when the quality of the cow’s milk supply 
is uncertain. It may also be delayed when the infant 
is convalescing from a recent illness or in the presence 
of epidemics of acute infectious diseases. 

Signs of Successful Nursing .—The normal full-term 
infant shows a gain of not less than 4 ounces (120 
gm.) weekly. This is the minimum weekly gain that 
may safely be allowed. When a nursing baby remains 
stationary in weight or makes a gain of only 2 or 3 
ounces (60 or 90 gm.) a week, it means that something 
is wrong, and the defect will usually, but not invaria¬ 
bly, be found in the milk supply. When the baby is 
nursed at proper intervals and the supply of milk is 
ample and of good quality, it is satisfied at the com¬ 
pletion of the nursing. Under 3 months of age it 
falls asleep after ten or twenty minutes at the breast. 
When the nursing period again approaches, it becomes 
restless and unhappy, crying lustily if the nursing is 
delayed. When the breast is offered, it takes it greed¬ 
ily. The weekly gain in weight under such conditions 
is usually from 4 to 8 ounces (120 to 240 gm.). At 



Fig. 5.—Average weight curve for normal infants during the first year. 


































































































































I 

































































’ 








. 






THE INFANT’S STOOLS 


29 


the fifth month the baby will have doubled, and at the 
twelfth month trebled its birth weight. The average 
gain for each week during the first year usually approxi¬ 
mates 5 ounces. 

Stools. —The feces of breast-fed babies are strikingly 
uniform and are like no other bowel movement in 
infancy. Normally there are two or three a day, 
sometimes only one, or, again, more than three. They 
are soft or mushy, homogeneous, of an egg-yellow or 
gold color, and have a slightly sour, not at all unplea¬ 
sant odor. They are never formed and always cling 
to the diaper. The nature of the bowel movement, and 
its uniformity, is due to the “physiologic fecal flora” 
which is brought about by the ingestion of breast milk 
into the germ-laden intestinal tract. The dominating 
organisms have a fermentative rather than a putrefac¬ 
tive action on the food. The gases normally formed are 
carbon dioxid and hydrogen, and these are almost odor¬ 
less. The acidity of the movement, its softness, and the 
mechanical action of the gases present, all insure active 
peristalsis and ready emptying of the bowels, so that 
true constipation is an exceptional condition in a breast¬ 
fed baby, and, if present, nearly always suggests too 
little food, or abdominal and intestinal muscles too little 
developed and too weak to force the stool past the 
anal sphincter. More often the stool is simply retained 
above the anus, owing to lack of peristalsis sufficient to 
overcome the anal sphincter. The latter condition is 
commonly interpreted as constipation by the laity. 

The feces of the breast-fed baby are frequently not 
wholly normal; they quite commonly, especially during 
the first few months, contain small, soft, white or 
yellowish fat curds, an excess of mucus, and are often 
greenish, and may be more frequent than normal. 
Such a condition is perfectly consistent with a normal 
growth and well-being of the baby , and should never 


30 


NURSING 


in itself be a cause of zvorry, or an indication for a 
change of food. This is a very important point that is 
commonly neglected. The condition of the bowel move¬ 
ments is only one factor, and in the breast-fed a minor 
one, in determining a baby’s nutrition. 

Signs of Unsuccessful Nursing. —The most signifi¬ 
cant symptoms are a stationary or insufficient gain in 
weight or losses in weight, fretfulness on the part of 
the infant while nursing, a tendency to remain for too 
long a time at the breast, and crying when it is removed 
from the breast. Small stools composed largely of 
mucus are usually an indication of insufficient food, 
especially when only one or two are passed daily. While 
every effort should be directed toward maintaining the 
breast-milk supply, it is of equal importance to interpret 
the symptoms of underfeeding as indications for com- 
plemental or supplemental feedings. 

Except in the presence of extreme emergency, breast 
feedings should not be discontinued suddenly. It is 
always wise to continue as many feedings at the breast 
as may be warranted by the circumstances in the indi¬ 
vidual case. 


CHAPTER V 


MIXED FEEDING AND WEANING 

The main indications for mixed feeding are: 1. To 
furnish sufficient food to meet the infant’s needs when 
the mother’s supply becomes inadequate. This is best 
accomplished by complcmental feeding by the adminis¬ 
tration of cow’s milk mixture after a limited period on 
the breasts. 2. To relieve the mother of one or more 
breast feedings to provide for her recreation. 3. To 
teach the infant bottle feeding in the preparation for 
emergencies. The two latter conditions will necessitate 
replacing breast by bottle meals. These are known as 
substitute feedings. Whichever of these two methods 
of extra feeding is adopted, the all important question 
to be answered for the mother is what foods and how 
much of them shall be given to replace the breast milk. 
It has been stated that average infants will require 
amounts approximating 2% ounces (75 c.c.) for each 
pound of body weight, of breast milk in twenty-four 
hours. 

It is necessary to weigh the infant before and after 
nursings for one or more days to obtain a fair idea 
of the amount of cow’s milk mixture that it will be 
necessary to administer in cases of underfeeding at the 
breast. Example: Given a normal infant weighing 
10 pounds (4.5 kg.), the food value of 25 ounces 
(700 c.c.) of breast milk should be approximated 
(one sixth of the body weight). Comparative deter¬ 
minations of human and cow’s milk show, on an aver¬ 
age, fat, 3.5 ; protein, 1.5 ; carbohydrate, from 6 to 7.5 in 
the former, and fat, 4.0; protein, 3.5; carbohydrate, 4.5, 
in cow’s milk. 

Clinical experience has taught us that most infants 
will thrive on artificial mixtures approximating the 


32 


MIXED FEEDING AND WEANING 


food values contained in breast milk. Roughly, 1% 
ounces (45 c.c.) of cow’s milk to which y 1Q ounce 
(3 gm.) of sugar (cane or milk) and 1 ounce (30 c.c.) 
of water has been added, will meet the requirements for 
each pound of body weight (0.54 kg.). 

It is a safe and rational plan to think of the infant’s 
needs in grams of fat, protein and carbohydrate for 
each pound of body weight. The breast-fed infant 
receiving 2% ounces per pound receives, fat, 2.6; 
protein, 1.1, and carbohydrate, 5.0 gm., daily for each 
pound of body weight. These values are approximated 
by U /2 ounces of cow’s milk with y 10 ounce of sugar 
and 1 ounce of water added (fat, 1.8; protein, 1.57; 
carbohydrate, 5.0). Example: A 10-pound infant 
receiving 15 ounces of breast milk is receiving 2y% 
ounces for each 6 pounds of his body weight, and will 
require in addition the equivalent of 2% ounces of 
breast milk for each of 4 pounds of body weight, which 
can be supplied by 6 ounces or one and one-half times 
four of cow’s milk, and f 6 7 l0 ounce of sugar. 6 To meet 
his water requirements, the mixture should be made 10 
ounces, adding 4 ounces of boiled or cereal water. 7 

The cow’s milk mixture can be divided into equal 
parts to be given from the bottle as complementary 
feeding following the breast nursings. 

The exception to these food requirements is the 
thin infant whose substitute feedings must approximate 
the requirements of his full weight for his age. It 
is to be remembered that small fat infants require 
less total food than large infants of the same age. 
(Further details for artificial feeding will follow.) 

Food Other Than Milk Mixtures .—Most infants 
may be given small quantities of orange juice during 

6. Two level tablespoonfuls of cane sugar equal 1 ounce; 3 level 
tablespoonfuls of milk sugar equal 1 ounce. 

7. One kilogram equals 2 % pounds; 30 c.c. (or 30 gm.) equals 1 
ounce. 



WEANING 


33 


the third month of life, even though they are exclu¬ 
sively breast fed. During the fourth month, small 
quantities of well-cooked cereals can be started, and 
during the early part of the second half year a vege¬ 
table and meat broth may be started to advantage. 
These additions may be made to the diet even when 
the breast milk supply is sufficient to meet the caloric 
requirements. Besides rounding out their diet, they 
prepare the infant to meet the emergencies of a 
diminishing breast-milk supply. 

WEANING 

Weaning should always be done gradually, when 
possible, for the sake of both mother and child. The 
first months in the life and development of a child 
are the most critical period. Weaning at this time is 
a serious matter. A well baby after he is 6 months 
old can, as a rule, be successfully weaned when neces¬ 
sary, if it is properly done. However, at least part 
breast feeding should be continued throughout the 
next three months, or even longer, if possible, depend¬ 
ing on the infant’s health, the season and the other 
circumstances. When a mother cannot give her infant 
at least two satisfactory breast feedings daily, it is 
advisable to wean the child. 

Sometimes a baby cannot take cow’s milk; in such a 
case milk from a goat may be tried. This has been of 
great value in some cases of exudative diathesis. 

As a rule, the trouble in weaning is not because the 
infant cannot digest cow’s milk, but because the change 
is made too suddenly or the food given at first is not 
properly adapted to the infant. 

In cases of sudden weaning, the food must be weaker 
in the beginning than for an artificially fed child of 
the same age. If weaned at 6 months, the infant 
should be put on a mixture for a child of 2 or 3 months, 


34 


MIXED FEEDING AND WEANING 


and the same rule applies for older infants. When 
the infant becomes accustomed to cow’s milk, the 
strength can be gradually increased. 

By gradually changing this way from breast feeding 
to bottle feeding, weaning can usually be completed in 
two weeks without upsetting the baby. It is very 
seldom necessary to wean in a shorter time than this 
and there is every reason to wean gradually so as to 
prevent any disturbance. Rarely should breast feeding 
be continued past the first year. 

The fear of the laity of the “second summer” is 
well founded when dirty milk and other improper 
foods are fed promiscuously; but with clean, certified 
and sterilized milk and properly prepared soft foods 
the dangers of the summer heat are minimized. It 
should be the rule to underfeed rather than overfeed 
in hot weather; during the extreme hot spells the 
diet may well be reduced by one third or even one half. 


CHAPTER VI 


THE PHYSICIAN 

It is necessary that the medical adviser, in order that 
maximum breast feeding may be maintained, shall 
impress on his patient that the instances in which the 
mother’s milk will not agree with her own baby are 
very rare; that the first few days and weeks form the 
most critical period in the nursing history, during 
which the mother and the infant are adapting them¬ 
selves to each other. During this period there is great 
danger that the distress and lack of gain in weight 
due to underfeeding may be misinterpreted as improper 
feeding. The scale used for measuring the twenty-four 
hour intake, by weighing before and after each feeding 
and the estimation of the gain in weight over given 
periods of time, must be the determining factors for 
the institution of complemental feeding. In order to 
establish a maximum milk flow, both breasts should 
be given at each feeding, but at not too short intervals, 
and if other food is necessary it should be given after 
the nursing and not in place of a nursing. Such a 
procedure will result in a maximum stimulation. 
When, through any cause, the infant is unable properly 
to stimulate the breasts, regular expression should be 
practiced. Mothers are to be taught that lactation can 
be reestablished even after the baby has been off the 
breast for some time. 

In private practice, in order to obtain the maximum 
breast feeding, it is necessary that routine consultations 
with the mother be inaugurated. These should begin 
shortly after the baby is born, by personal instruction 
to the mother as to the best means of promoting her 
breast milk supply through proper hygiene and diet, 
on her own part, and regular stimulation of her breasts 
by the baby or by expression of milk or a combination 


36 CONSULTATIONS WITH THE MOTHER 


of these methods. When the activities of the physician 
do not permit such instruction it should be given by 
a trained nurse or some one who has had practical 
experience along these lines. 

In not a few instances, even in the presence of good 
breasts, during the first few weeks the breast milk 
supplied by the mother will not meet all the require¬ 
ments of the infant, and occasionally this period of 
insufficient supply may run into the second month. In 
all such cases coinplemental 8 feeding becomes neces¬ 
sary. With improvement in the mother’s general 
health and her assumption of her normal activities, 
the breast milk supply increases, and repeatedly we 
have seen what at first seemed a hopeless case for 
complete breast feeding develop into one in which the 
infant could be supplied with all of its needs until the 
time arrived at which mixed feeding was the diet of 
choice. Such cases are especially common among the 
very young and old primiparas, and these are the ones 
who require the greatest amount of encouragement. 

It therefore becomes the duty of the physician, in 
order that the mother may assume her full responsi¬ 
bilities toward her infant, to see the infants in their 
practice at regular intervals during the period of lacta¬ 
tion. Weekly or bimonthly consultations during the 
first month, and monthly visits during the remainder 
of the nursing period are not only to be recommended 
but in many instances are imperative for the best 
interests of the infant. Breast feeding is rarely 
considered a burden by the young mother when the 
four-hour nursing period has been established, and in 
case of emergency it is usually possible to express suffi¬ 
cient milk to satisfy infants, should it become impossi¬ 
ble for the mother to be present at the feeding hour. 

8. Complemental feeding is the administration of a bottle following a 
period at the breast; substitute feeding the replacing of a breast by a 
bottle feeding. 



NUTRITIONAL DISTURBANCES 


37 


Disturbances in Breast-Fed Infants 

Breast milk is a complete food and contains all the 
essentials of a well-balanced diet for the human infant. 
Notwithstanding the fact that there is a considerable 
difference in the chemical composition of milks from 
different sources, the average infant will thrive on 
them. However, nutritional disturbances are of 
common occurrence in the breast fed; and while, on 
the whole, they are less dangerous than similar dis¬ 
turbances in bottle-fed infants, they should receive 
early and serious consideration. 

Those most commonly seen fall within one or more 
of the following groups: (1) underfeeding; (2) 
overfeeding; (3) congenital debility, with resulting 
impairment of the vital functions; (4) intercurrent 
parenteral (pharyngitis, tonsillitis, bronchitis, pneu¬ 
monia, pyelitis, etc.), and enteral infections, and (5) 
idiosyncrasy toward mother’s milk. 


CHAPTER VII 


UNDERFEEDING 

The diagnosis will be dependent on an estimation 
of the quality and the quantity of milk received by 
the infant. The clinical picture as presented by the 
infant is the predominating factor that leads the 
physician to an investigation of the underlying elements 
causing its lack of progress. 

The quantity of the twenty-four hour supply is 
ascertained by weighing the infant before and after 
each nursing without change of garments. An accurate 
beam scale should be used. Most infants require from 
2 to 2% ounces (60 to 75 c.c.) of breast milk per pound 
of body weight in twenty-four hours. 

SYMPTOMS 

Dissatisfaction on the part of the infant with its 
individual meals is usually the first evidence of under¬ 
feeding. This is usually followed by restlessness and 
crying before the nursing time is due. Again, it may 
manifest its dissatisfaction by nursing greedily for a 
short time, releasing the breast and crying. In some 
instances it cannot be induced to remain at the breast 
because of the difficulty it encounters in obtaining its 
food after the first few minutes; or, on the other hand, 
there may be a tendency to prolong its feeding time. 
These symptoms are usually soon followed by a period 
of stationary weight or a loss in weight. 

Usually the stools are normal in appearance, but 
small in amount, and give little evidence of the cause 
of the trouble. However, if the food supply is 
decidedly insufficient, we may have a positive evidence 
of the underfeeding by the appearance of the so-called 
“hunger stools,” which are brownish or greenish brown 
and contain little fecal matter and much mucus. 


TREATMENT 


39 


If the condition is not corrected, the baby becomes 
weak and apathetic. The skin loses its turgor, its 
temperature becomes subnormal, it is pale and anemic 
and the fontanels become depressed and the abdomen 
sunken. Whenever there is room for doubt as to the 
cause of this group of symptoms, the scale will furnish 
the most positive evidence. 

TREATMENT 

The first step necessary in the institution of a 
rational regimen is to ascertain whether the fault is 
to be found in the mother or in the infant. On the 
part of the mother, it may be due to her physical 
condition or lack of glandular tissue in the breasts. 
Or, again, the infant may have some deformity or 
infection of the mouth interfering with nursing, or it 
may be too weak to continue its nursing to the end. 
If the infant is not getting enough food, artificial food 
must be supplied, temporarily, as part of the diet. 

Undue haste in removing the baby from the breast 
offers the greatest danger in the treatment of under¬ 
feeding and should be resorted to only when other 
means fail. The ability to increase the quantity of 
milk secreted by the average woman must necessarily 
vary directly with the quantity and quality of the 
glandular tissue composing the breast. However, to 
a certain extent at least, certain factors will more or 
less directly influence the quantity and quality of the 
secretion and they are worthy of our attention. 

If the trouble is due to an actual insufficiency in 
the milk supply, careful attention must be paid to the 
hygiene of the mother. She must have plenty of rest 
and sleep, her surroundings must predispose to a happy 
frame of mind, she must not be overburdened with 
household cares and her exercise must be regular. If 
possible, she should be freed from all care of the baby 


40 


UNDERFEEDING 


at night. She should eat sufficient food and drink 
plenty of liquids. Every effort should be made to 
stimulate her appetite, so that she will take an abun¬ 
dance of milk and other nutritious foods; but she 
should not be forced beyond her natural appetite, even 
in the taking of fluids. The general rules previously 
mentioned for the mother’s diet should be followed. 
An excessive diet may be assimilated by the mother’s 
body without increasing the flow of milk. 

The diet recommended should be palatable to the 
nursing mother, as previously recommended. 

Stimulating massage, combined with expression, may 
be applied to the breast in such a manner as to stim¬ 
ulate the whole gland. This can best be accomplished 
by two movements : By gently raising the whole breast 
from the chest wall and kneading it gently between 
the fingers, and by holding the breast against one hand 
and making circular movements against the periphery 
with the outspread finger-tips of the other hand and 
gradually working from its base toward the nipple. 

Baths at a temperature comfortably cool (from 80 
to 90 F.) should be taken daily to promote the mother’s 
general health as well as cleanliness. These should be 
followed by a brisk rubbing with a coarse towel. 

Steaming the breast by the application of hot towels 
covered with oil silk two or three times daily is of 
decided benefit. 

Galactagogues are of questionable value. General 
tonics will often improve the digestion and tend to 
overcome anemia, and in this way improve the general 
health and thereby lactation. If after such methods 
the mother’s milk is still insufficient, mixed feeding— 
part breast feeding and part bottle feeding—may be 
given for weeks or even months. One bottle feeding 
a day should be given in place of the breast, and the 
bottle should be given after each of the other breast 


TREATMENT 


41 


feedings to make lip the necessary amount. The baby 
should be encouraged to empty the breasts. 

When part breast milk and part cow’s milk is given, a 
well baby will usually have no difficulty in digesting 
the cow’s milk. In case the baby is disturbed or sick, 
the bottle can be stopped for a few days and the diet 
limited to breast milk and boiled water. Carbohy¬ 
drates can usually be added to the water to advantage, 
in the form of cereals and sugars. 


CHAPTER VIII 


OVERFEEDING 

In the normal breast-fed baby, overfeeding is not of 
frequent occurrence and is usually of temporary impor¬ 
tance, except in very young and premature infants and 
in those infants fed by gavage. The condition is usually 
corrected spontaneously by refusal of the infant to 
nurse longer than is necessary to meet its needs. When 
the breasts remain unemptied, the milk secretion soon 
decreases. The temporary overfilling of the stomach 
is usually satisfactorily relieved by a regurgitation of 
part of the meal. There always remains some danger 
of the stomach’s becoming accustomed to this tendency 
to reversed peristalsis. It is most commonly seen 
during the first weeks of life before the mother’s breasts 
and the baby have become adapted to each other. 
Overfeeding in infants fed by gavage may lead to 
dilatation of the stomach when the food is too rapidly 
administered, and this may lead to grave symptoms. 

ETIOLOGY 

Too frequent feeding is the most common cause; less 
frequently, too prolonged feedings. Excessive quan¬ 
tities of milk from a free flowing breast are usually of 
temporary importance when the infant is nursed by 
the mother, but are more likely to be a factor when 
infants are nursed by a wetnurse, more especially when 
her breasts are kept active by the nursing of a second 
infant. Milk excessively rich in fat and sugar may 
lead to nutritional disturbances. 

Ordinarily the stomach of a breast-fed infant empties 
itself in about two hours. The period between nursings 
during which the stomach is empty is one of consid¬ 
erable importance in that during this period, free hydro¬ 
chloric acid is present. Besides its antiseptic properties, 


SYMPTOMS OF OVERFEEDING 


43 


it assumes an important role in stimulating the secre¬ 
tion of pancreatic juice and bile, both of which have 
an important bearing on digestion. Too frequent nurs¬ 
ings interfere with these normal physiologic processes. 
Excessive quantities of food, even at proper intervals, 
impose too great demands on the gastric mucosa. When 
the food contains excessive quantities of fat, gastric 
secretion becomes diminished. 

SYMPTOMS 

The earliest manifestations of overfeeding are regur¬ 
gitation, anorexia, irritability and, not infrequently, 
diarrhea. Regurgitation occurs at first only occasion¬ 
ally, immediately after nursing, and without any dis¬ 
comfort on the part of the infant (spitting). The 
regurgitated fluid is often unchanged milk. This is 
usually the first premonitory symptom. 

Diarrhea follows when overfeeding continues and 
regurgitation becomes insufficient to rid the body of 
excess food. This is especially true when the milk is 
high in its fat and sugar content during the first weeks 
of life. The stools are more frequent than normal, and 
contain undigested particles of food. The irritating 
feces often cause intertrigo in the anogenital region. 

In many cases no other symptoms develop, the con¬ 
dition undergoing a spontaneous cure. The breasts 
lessen their yield, and thus the cause of the condition 
disappears, or, on the other hand, the digestive power 
of the infant increases to such an extent as to be able 
to take care of the excess, if not too large. When, 
however, these disturbing factors are entirely neglected, 
the excess of the food continued, or even increased, 
owing to wrong interpretation of symptoms, then more 
serious symptoms develop. 

Vomiting becomes habitual, occurring from a few 
minutes to half an hour after nursing. It is accom- 


44 


OVERFEEDING 


panied by visible discomfort and straining on the part 
of the infant. The vomitus consists of curdled milk, 
mucus and gastric juice. Between vomiting, there is 
often painful belching. The stomach shows distention, 
and empties itself only after three or four hours. Free 
hydrochloric acid is reduced or may be absent, the acid 
products of fermentation being present. The micro¬ 
organisms are increased in number and variety, owing 
to stagnation and absence of antiseptic free hydro¬ 
chloric acid. 

The weight early becomes stationary; in severer 
cases, associated with diarrhea, loss of weight becomes 
marked. 

DIAGNOSIS 

There is great danger of making a diagnosis of over¬ 
feeding in infants sick from other causes. As previ¬ 
ously stated, it is, on the whole, a rare condition in 
normal infants. In the presence of symptoms suggestive 
of overfeeding, positive diagnosis is made by determin¬ 
ing the amount of milk taken by the infant, and com¬ 
paring it with amount an infant of the same age and 
weight should get. 

If, however, the food is found to be quantitatively 
correct, occasionally information of value may be 
obtained by examining the quality of the milk chem¬ 
ically, especially as to its fat and sugar content. The 
specimen for examination should be taken under pre¬ 
cautions pointed out under “Examination of Human 
Milk.” By making a proper etiologic diagnosis, valu¬ 
able indications for rational treatment are obtained. 

COMPLICATIONS 

Pylorospasm and gastric dilatation are not uncommon 
in the neglected cases. 

Diarrheal disturbances are accompanied by the milder 
evidences of intestinal irritation, such as colic, and more 


COMPLICATIONS AND TREATMENT 


45 


or less numerous bowel movements—acid and irritating, 
greenish-yellow, and containing numerous curds and 
much mucus. The buttocks soon become reddened, 
and intertrigo results. 

Anhydremic intoxication, complicated by acidosis, 
while rare in the breast-fed infant, may result when the 
vomiting and diarrhea are neglected. The baby becomes 
drowsy and stuporous, pays little attention to its sur¬ 
roundings, and not infrequently develops an extreme 
anorexia. 

In simple diarrheal disturbances, the intestinal find¬ 
ings dominate the picture, while in intoxication they 
share their prominence with the added nervous 
symptoms. 

Eczema not infrequently results from overfeeding in 
the breast-fed infant, and is usually seen in the fat 
type of infant who is otherwise healthy. 

Pyelitis is a frequent complication in neglected cases 
of diarrhea. 

TREATMENT 

The prophylaxis of this condition is of importance, 
and consists in giving the mother proper instructions as 
to the nursing, especially as to its frequency, and seeing 
to it that the rules covering the interval, number of 
nursings and time at the breast are observed. In wet- 
nursing, more caution is necessary, especially in those 
wetnurses who have an abundance of milk, which is 
frequently the case in a wetnurse whose child is older 
then the infant nursed. 

A very important point to impress both on the mother 
and on the wetnurse is the fact that crying of the 
infant is not always due to hunger, and that offering 
the breast should not be used as a means for quieting 
the child. 

When the flow of milk is very free, it may be neces¬ 
sary to reduce the nursing period to even three to five 


46 


OVERFEEDING 


minutes, it being a fact that most infants take about 
75 per cent, of their entire meals in the first five min¬ 
utes at the breast. It is always well at the beginning 
of such an experiment to weigh the baby after a two, 
three, five, ten and twenty minute period to ascertain 
the exact amount which the baby obtains from the 
particular breast which it is nursing, so that conclu¬ 
sions may be drawn as to the time it is to be left on 
each breast. If the short nursing periods with increased 
intervals do not result in a lessened secretion and relief 
of the symptoms, the milk should be expressed and 
fed by hand in measured quantities. 

When the breast milk contains an excess of fat, this 
is most easily remedied by reducing the mother’s diet 
as a whole and increasing her exercise and water 
intake. 

When the infant shows evidence of gastric distention 
and retention, the treatment consists in emptying the 
stomach and bowels of the overload of fermenting 
food, and resting the digestive apparatus, both these 
objects being achieved by giving a bland diet, con¬ 
sisting of boiled water, or weak tea sweetened with 
saccharin, for twelve hours. 

If vomiting continues, it is advisable to wash out 
the stomach with physiologic sodium chlorid solution 
or 1 per cent, sodium bicarbonate solution. 

Irrigation of the bowel aids in removal of fermenting 
intestinal contents. 


CHAPTER IX 


IN TERCURRENT PARENTERAL AND ENTERAL 

INFECTIONS 

Infections in the mother or infant may be the caus¬ 
ative factors of nutritional disturbances. In the mother 
the most important are puerperal fever and sepsis, the 
acute infectious diseases, and local infections of the 
breasts. In the infant, infections outside the digestive 
tract, such as pharyngitis, tonsillitis, pneumonia, 
pyelitis and bronchitis, are classed as parenteral infec¬ 
tions, and those of the intestinal tract as enteral 
infections. 

SYMPTOMS 

If the mother is ill, the clinical picture will vary, 
depending on whether the infant becomes infected by 
the contact, or suffers only through a diminished food 
supply. Conditions in the mother which would justify 
weaning have been discussed. 

In conditions following infections in the infant, the 
symptoms depend on whether the infection is local, 
systemic or confined to the intestinal tract. The clin¬ 
ical picture varies directly with the degree of disturb¬ 
ance of the metabolic function. As a rule, the enteral 
infections are more commonly associated with grave 
disturbance of the infant’s nutrition. Parenteral infec¬ 
tions also interfere with the processes of metabolism 
necessary to meet the nutritional needs. Undoubtedly, 
in many of these a secondary enteral infection results 
from ingestion of bacteria from the upper respiratory 
tract. 

The diagnosis of the primary seat of infection in the 
infant is of considerable importance in deciding the 
method of treatment. 


48 


TREATMENT 


TREATMENT 

Parenteral infections rarely call for restraint in 
administration of food because of the associated 
anorexia, and the infant should be nursed (if possible 
without danger to the mother) directly at the breast. 

In the case of enteral infections, it may be neces¬ 
sary to withdraw the maternal milk and replace it by a 
short period of starvation, to be followed by small 
quantities of breast milk, taken directly from the 
breast during short nursings, or it may be best to feed 
small quantities of expressed milk to the infant at 
regular intervals. 

Not infrequently it becomes necessary to feed these 
infants by catheter in order to sustain them. This 
method of introducing their food should be begun 
sufficiently early to avoid a catastrophe. 

Under no circumstances should they be placed on 
food other than the mother’s milk when the state of 
her health and the quality of her milk permit. 

Inert fluids, such as water, weak tea, broths made 
from young, meat and young fowls, and cereal decoc¬ 
tions, should be given between feedings to insure a 
sufficient intake of water, the infant’s age permitting. 
A careful record should be kept of the twenty-four 
hour quantity of all fluids administered, in order to 
insure the child a sufficient water and food 
administration. 


CHAPTER X 


IDIOSYNCRASY TOWARD MOTHER’S MILK 

The cases in which the mother’s milk is totally unfit 
for the infant’s use are exceptionally rare. More 
recently, considerably more attention has been given to 
the effect of the mother’s diet on the quality and quan¬ 
tity of her milk secretion. The instruction so com¬ 
monly given to the mother to the effect that she may 
eat whatever she likes has, in the light of more recent 
investigations, shown need for modification. The 
effect of the diet of the mother on the milk must be 
considered under two headings; first, what foods dis¬ 
agree with the individual mother to the extent of 
affecting the quantity of her milk supply. The mother 
will be the best judge as to what foods she herself finds 
it desirable to eliminate from her diet because of an 
undesirable effect on herself. More important, how¬ 
ever, from the standpoint of food idiosyncrasy is the 
result following the eating of foods by the mother 
which she herself may relish, but which may have an 
undesirable effect on the child. It is well known that 
eggs, some cereals, fish and sea foods, certain meats, 
chocolate, and even cow’s milk proteins, when ingested 
by the mother, may result in a sensitization of the infant. 

The more recent work of O’Keefe 9 demonstrated the fre¬ 
quency of such a sensitization in eczema. Sixty-one per cent, 
of forty-one cases showed a positive reaction to one of the 
cow’s milk proteins. Forty-one per cent, showed a positive 
reaction to one of the egg-proteins, two cases to oats, and 
one to wheat. About 20 per cent, of the positive cases showed 
a response to both milk and egg proteins. Apparent cure in 
about 20 per cent, more followed the omission or limitation 
in the maternal diet of one or more food proteins to which 
the infant was sensitive. 

9. O’Keefe, E. S.: Eczema in Breast-Fed Babies, Boston M. & S. J. 
185 : 194 (Aug.) 1921. 




50 


IDIOSYNCRASY AND SENSITIZATION 


Talbot 10 reports a case in which a very severe eczema 
cleared up on the mother’s discontinuing the eating of choco¬ 
late, and recurred on her again eating that food. 

By a series of experiments, Shannon * 11 was able to demon¬ 
strate that two infants under his care, who were suffering 
from urticarial skin lesions, had become sensitized to egg 
protein ingested by the mother. He in turn sensitized a 
series of guinea-pigs by the injection of the breast milk 
from these women, and was able to precipitate anaphylactic 
reactions by intrathecal injection, when eggs were added to 
the mother’s diet. 

Cases of Egg Anaphylaxis .—The grandmother of a patient 
presented no idiosyncrasy following ingestion of eggs, until 
the time of her first pregnancy, when during the fifth month 
she ate eight eggs in one day. Since that time, twenty-four 
years ago, she never has been able to relish eggs. Her first 
child was unable to eat eggs or anything containing eggs 
during her childhood, but during her later years she has 
been able to eat food containing a moderate quantity of egg. 
She has no children. Her second child, the mother of the 
patient, gave the same history, stating that she could detect 
the smallest quantity of egg in pastry, at the first taste. The 
patient had been a well infant until seen at 8 months, when 
it was still exclusively breast-fed, and had developed a severe 
diarrhea. For twelve hours it was placed on barley-water, 
with instructions to add the white of one egg to a pint of 
barley water during the subsequent twelve hours. It partook 
of 1 ounce of this mixture cf barley water and egg albumin. 
Within thirty minutes, it became violently ill, with vomiting 
and purging, and shortly thereafter developed marked edema 
of the entire body. This lasted for six hours, when it receded 
spontaneously. When a slight abrasion was made with a 
Pirquet scarifier, and a drop of egg albumin was applied to 
the abrasion, a white wheal, one-half inch in diameter, devel¬ 
oped within six minutes, continuing to increase in size for 
fifteen minutes, when it was surrounded by an erythematous 
area, 1 inch in diameter; throughout this erythematous area, 
numerous pin-head sized white elevations developed. The 
entire reaction disappeared in one and a quarter hours. 

10. Talbot, F. B.: M. Clin. N. Am. 1 : 985 (Jan.) 1918. 

11. Shannon, W. R.: Demonstration of Food Proteins in Human 
Breast Milk by Anaphylactic Experiments on Guinea-Pigs, Am. J. D'is. 
Child. 22 : 223 (Sept.) 1921. 



CHAPTER XI 


CARE AND FEEDING OF PREMATURE 

INFANTS 

Preparation for the care and protection of pre¬ 
mature infants, in order to insure them the best oppor¬ 
tunity for survival, must be started with the first inti¬ 
mation that labor is to begin, if spontaneous; and, 
when labor is to be induced, the infant, as well as the 
mother, should receive the best thought of the physi¬ 
cian. The infant must be protected from the dangers 
of refrigeration, skilled nursing care must be supplied, 
and it must receive a suitable diet. 

PRESERVATION OF BODY TEMPERATURE 

Even though the mother may be so situated as to 
receive proper attention in the home, if facilities for 
caring for the infant are not at hand, the confinement 
should be conducted in a properly equipped hospital. 

Syphilis should be suspected as a possible cause in 
all cases of premature birth. 

The labor should be conducted with the strictest 
attention to asepsis, because of the high mortality fol¬ 
lowing infections in this class of infants. Every effort 
should be made to prevent chilling of the infant imme¬ 
diately after birth. Owing to the instability of the 
heat-regulating centers, the infant’s body temperature 
is rapidly affected by its surroundings. It should be 
received in a heated blanket and placed in an impro¬ 
vised heated basket or incubator bed, as soon as pos¬ 
sible after the cord has been severed. The face alone 
should be left exposed. Protection is best afforded by 
a cotton pack, or, better still, by woolen garments. A 
nurse or another person experienced in the handling of 
infants should be assigned to the care of the baby and 


52 


PREMATURE INFANTS 


give it her entire attention so that spells of asphyxia 
and cyanosis may receive the immediate attention of the 
physician. As a rule, the initial bath should be omitted 
until the infant, if it is a small one, has adapted itself 
to its new environment. Every effort should be 
directed to the prevention of overheating and burning 
infants, as they do not resist high temperatures to much 
better advantage than they do refrigeration, and they 
are easily burned; and burning, even though slight, 
would be associated with a high mortality. The room 
in which the infant is placed should be light and easily 
ventilated, without being cooled to a greater degree 
than may be desired. If the room temperature can 
be kept between 72 and 75 F., a well protected basket 
or crib can be temporarily heated to meet the infant’s 
needs by surrounding it with hot water bottles placed 
a sufficient distance from and properly protected so that 
contact with the infant will be avoided. An electric 
pad protected by an insulated copper jacket will answer 
the purpose when placed under the pillow on which the 
infant rests. Suitably equipped obstetric departments 
are usually furnished with a heated bed as part of 
their permanent equipment. It is rarely necessary to 
surround the infant with a temperature greater than 
from 85 to 88 F., and usually it can be reduced to 
80 F. in a few days except in the case of the smallest 
infants. A thermometer should be placed alongside 
the baby under the robes used as a covering. 

Aseptic nursing is imperative to the welfare of these 
small infants. This applies to linens, clothing, ther¬ 
mometers and also utensils used in the care of the baby. 
During the bath, whether by sponging or by tubbing, 
it must be protected from chilling and infection, and 
of equal importance is the prevention of scalding. The 
water should be tested by allowing the hand to remain 
in the water for at least thirty seconds before placing 


CLOTHING FOR PREMATURE INFANTS 53 


the baby in the bath tub, if it is to be tubbed. The 
baby should be bathed in a warm room. After the 
first dressing, all garments which come in contact with 
the body, except the napkin, should be made of a 
medium weight flannel, as the infant is best protected 
by woolen garments. As an outer garment it may be 
wrapped in a woolen blanket or one made from non¬ 
absorbent cotton between cheesecloth which has been 
quilted to protect it. A more permanent gown may be 
made of blanket material or eider-down in the form of 
a rectangle of sufficient size to surround the body and 
permit pinning over the feet. To this may be attached 
a smaller square at the top which will fold over the 
head and allow the face to remain exposed. A more 
permanent sleeping bag may be made of similar 
material. These have a disadvantage of requiring con¬ 
siderable handling of the infant for changing napkins 
and inspecting the genitalia. The most practical gar¬ 
ments for the infant consist of a light-weight wool 
flannel undershirt with blind sleeves, so that the hands 
remain covered. Above this an overshirt of a heavier 
flannel or French pique is to be worn. The extremities 
are wrapped in a flannel pinning skirt or blanket, 
fastened to the overshirt by small safety pins. The 
advantage of this type of clothing is that soiled napkins 
can be removed without exposing the upper part of the 
body, and the handling of the infant is at a minimum. 
A small pad of cotton should be placed inside the napkin 
so that the outer clothing may be better protected. The 
diaper should be changed as soon after soiling as possi¬ 
ble, and this in itself will require regular inspection. It 
should therefore be dressed accordingly. The impor¬ 
tance of properly clothing these infants becomes evident 
when consideration is given to the fact that they stand 
handling very poorly. As the infant becomes older, its 
clothing should be similar to those used in full term 


54 


PREMATURE INFANTS 


infants so that it may have freedom for its extremities. 
The position of the infant should be changed at stated 
intervals in order to prevent hypostasis. 

WORK OF THE NURSE 

The nurse should appreciate the requirements of her 
charge. She must be willing to make necessary sacri¬ 
fices while the infant is passing through its first critical 
days, and must be properly instructed to meet the 
emergencies of asphyxia and to counteract the spells of 
cyanosis. These will require almost constant diligence. 
She must also be possessed of good judgment in the 
matter of feeding, in order to avoid both underfeeding 
and overfeeding. She must also be able to appreciate 
the indications for and the methods of administering 
catheter feeding, as well as the simpler methods by use 
of the medicine dropper or miniature feeding flasks. 
She should be instructed in the proper preparation and 
tubbing of the infant for its bath, the giving of low 
colonic flushings, and the application of artificial 
respiration. 

FEEDING 

The majority of prematurely born infants will nut 
survive artificial feeding; therefore, the difficulty in the 
interpretation of the needs of the individual infant 
should lead to the conclusion that a supply of breast 
milk is imperative to fulfil the food requirements of 
these infants in order to insure a low mortality. The 
administration of the feedings ofifers no difficulties 
which cannot be overcome if the infant is viable, per¬ 
sistent vomiting is absent, and breast milk is at hand. 
No definite rules can be outlined as to the quantity to 
be given at each feeding, and the same statement applies 
to the interval between feedings. This statement 
implies that each infant must be fed to meet its 
individual needs. 



Fig. 6.—Bag for carrying prematurely born infants. 





































■ 










































- 




'» 























FEEDING PREMATURE INFANTS 


55 


For the purpose of feeding, premature infants must 
be divided into two large classes: (1) those able to 
nurse directly from the breast, and (2) those which 
will require hand feeding. If the infant is sufficiently 
developed to nurse from a well formed nipple, it should 
be placed at the mother’s breast two or three times 
during the second twelve hours after birth and, follow¬ 
ing this, at three-hour intervals. The nursing period 
should, however, be short at first, beginning with two 
or three minutes at the breast, as this will soon educate 
the child to expect its food at regular periods. It will 
also help to stimulate the mother’s breasts, as well as 
to develop the infant’s sucking muscles. 

During the first days, until there is sufficient flow of 
milk, the infant must receive its breast milk from 
another source. The necessity of an early supply of 
food cannot be overemphasized, as even the better 
developed infants do not withstand prolonged starva¬ 
tion. When a wetnurse is available and her infant is at 
hand, her baby can be used to stimulate the breasts 
of the mother, and the premature infant can be placed 
on one of the breasts of the wetnurse. In‘the case of 
very weak infants, the breast designated for its use can 
be made to secrete more freely by placing the wet- 
nurse’s baby on the opposite breast during the feeding 
period. As a weak infant may receive only a very 
limited amount of milk, even after a prolonged period 
at the breast, a proper scale is a necessary part of the 
equipment, so that it may be weighed before and after 
feeding. There is far less danger from overfeeding 
because a too rapid flow or an excessive amount usually 
results in regurgitation, and this can easily be remedied 
by shortening the period at the breast. The capacity 
of the stomach in some of the smaller infants, even 
though they are able to nurse at the breast, is such that 
shorter intervals may be necessary. They may be 
nursed at two or two and one-half hour periods. 


56 


PREMATURE INFANTS 


FEEDING DURING THE FIRST DAY 

During the first day, milk may be withheld for 
twelve hours until the respiratory and circulatory 
functions are well established. During the second 
twelve hours, from one to three feedings of breast milk 
may be started if the infant’s condition warrants. 

FEEDING FROM THE SECOND TO THE TENTH DAY 

For practical feeding purposes, the second to the 
tenth days may be grouped as the second feeding period. 

From the second day the infant should be fed 
regularly, day and night, the number and time of feed¬ 
ings depending to a great extent on (1) whether the 
food is given with or without the use of a catheter; 
(2) the gastric capacity, and (3) the infant’s general 
condition. 

Further fluids, preferably inert, such as water nr 1 
per cent, lactose solution, are administered to compen¬ 
sate for the loss of body fluids through the kidneys, 
bowels, lungs and skin. The infant requires about 
one sixth of its body weight of water, inclusive of that 
contained in the milk, in twenty-four hours while in 
the heated bed. Such quantities, however, should not 
be attempted on the first days; usually it will be pos¬ 
sible to approximate one eighth of the body weight by 
the fourth day. The early feedings must necessarily 
be small, and the increases gradual. 

Each infant must be fed individually, as it is impos¬ 
sible to formulate definite rules for feeding, at least 
during the first ten days. The physician must have a 
definite idea of (1) the minimal food requirements 
for life; (2) the amount of food necessary to main¬ 
tain at least a stationary weight, and (3) the amount 
of food needed to meet the requirements for growth 
and development. 


THE FIRST TEN DAYS 


57 


Approximately one seventh of the body weight of 
fluids and human milk of a food value of 70 calories 
per kilogram every twenty-four hours are required to 
maintain life. Little can be expected in the way of 
weight increase until 90 calories is reached; and, 
depending on the weight, body surface, and physiologic 
development, the later needs of infants will approxi¬ 
mate from 100 to 140 calories per kilogram of body 
weight. 

Infants, to fulfil all their needs, will therefore 
require from 140 to 200 c.c. of breast milk per kilo¬ 
gram, or from one seventh to one fifth of their body 
weight daily. They can, however, maintain life on 
100 c.c., and hold their weight in most cases on 130 
c.c. per kilogram. 

Beginning (in most cases by the second day) with 
from 20 to 40 c.c. of human milk per kilogram of 
body weight, the quantity may be increased by from 
8 to 15 c.c. daily per kilogram until, usually by the 
tenth day, feedings averaging from 80 to 140 c.c. per 
kilogram can be fed. 

These feedings should, as rapidly as possible, be 
supplemented by water or sugar-water by mouth, or 
saline by rectum to meet the required 140 to 200 c.c. 
per kilogram of fluids required daily. 

After the tenth day, in larger infants the milk can 
be increased more rapidly, usually by 15 and occa¬ 
sionally 20 c.c. per day, until from 140 to 200 c.c. 
per kilogram are fed, the methods of giving the food, 
as well as its frequency, being dependent on the 
general development of the infant. 12 

The size of individual feedings will vary with the 
method of feedings. When the infant is catheter fed, 

12. One kilogram equals pounds; 30 c.c. equals 1 ounce; 4 c.c. 
equals 1 dram; 1 ounce of breast milk contains 21 calories; 100 c.c. 
of breast milk contains 70 calories. 




58 


PREMATURE INFANTS 


from six to eight feedings a clay are given, with an 
average of from 4 to 6 c.c. for each feeding during 
the second day. The feedings are now increased 
daily by an average of 2 c.c. at each feeding. When 
feeding from the bottle or by dropper is employed, 
smaller feedings are usually given more frequently, 
usually from eight to ten daily, although twelve may 
be needed when larger feedings are not retained. Begin¬ 
ning with from 2 to 4 c.c., one may increase by 1 or 
2 c.c. each feeding on each succeeding day, until from 
140 to 200 c.c. per kilogram daily is reached. 

The food and water to be administered should be 
noted in writing for the nurse’s instruction each day, 
after a thorough inspection of the infant and its 
clinical chart. 

The diet of a premature infant making a satisfactory 
gain in weight should not be changed arbitrarily with¬ 
out a well-defined indication. 

Initial Weight Loss. —The lower the birth weight, 
the greater is the percentage of weight loss to be 
expected. Artificially fed infants lose more weight 
than breast-fed infants in whom the diet is started 
early. An average loss of not more than 8 to 12 
per cent, of the birth weight may be considered satis¬ 
factory. By regular administration of inert fluids 
during the first days, the total loss can frequently be 
reduced to 5 per cent. 

Daily Gains. —These are not necessarily in propor¬ 
tion to the changing quantity of milk administered, 
as many factors—the condition of the bowels, the 
quantity of urine passed, the temperature of the 
infant’s surroundings, and numerous others — will 
necessarily influence the weight. 

An average daily gain greater than 20 gm. is 
unusual when the infant’s food is limited to one fifth 


SPECIAL FEEDING RULES 


59 


of its body weight. Although occasionally an infant 
holds its birth weight, most infants do not regain their 
birth weight before the end of the second or third 
week. 

In the very small premature infants, an average 
daily gain of from 10 to 15 gm. with a doubling in 
birth weight in from seventy-five to 100 days may be 
considered satisfactory. In the larger infants, a gain 
of from 15 to 20 gm. may be expected with a doubling 
in birth weight in from fifty to 100 days. The birth 
weight is frequently trebled within ISO days. 

SPECIAL FEEDING RULES 

1. Food requirements which have been recommended 
must of necessity be considered as relative, variations 
being to a great extent influenced by the physiologic 
and anatomic developments and to a not inconsiderable 
extent by the temperature and humidity of the air sur¬ 
rounding the infant and the type of clothes in which 
it is dressed. 

2. Each day the total amount of food as indicated 
for the individual infant is to be estimated, in order 
that the required food and water may be properly 
administered. The number and amount of feedings 
will of necessity vary, but each must also be estimated 
for each day. 

3. When a number of infants are to be fed by one 
wetnurse, careful calculation of the day’s needs of 
each infant must be made by the floor nurse for the 
information of the nurse in charge of the milk supply. 

4. Expression of breast milk should be performed at 
regular intervals, preferably six times a day at four- 
hour periods day and night. The sixth expression 
during the night may, however, be omitted if the supply 
is in excess. It is only by regular and complete empty¬ 
ing of the breasts by expression that a milk supply 


60 


PREMATURE INFANTS 


can be maintained for an indefinite period, unless there 
is a second baby which can be placed at the breast. 

5. Human, as well as cow’s milk, must be obtained 
under aseptic conditions and kept clean and cool until 
feeding time. To preserve milk properly, the icebox 
must register less than 50 F. The food should be 
slowly warmed before feeding. 

6. The amount of water to be fed must be care¬ 
fully calculated, and it must represent the difference 
between the total fluids indicated, which will usually 
average from one eighth to one fifth of the body weight 
of the infant for twenty-four hours and the amount 
of fluid given as milk. The zrnter for each day should 
he measured and set aside in an individual stoppered 
bottle each morning. 

It should be administered between the milk meals; 
or, occasionally, there may be an indication for diluting 
the milk with part of it. In order to administer the 
full day’s water supply in some of the small infants 
and those who vomit, it may be necessary to give w^ater 
in small quantities one, two and even three times 
between milk feedings. If the infant is unable to 
swallow properly, water must be given by catheter. 
In larger infants only a few water feedings a day 
may be needed, and usually by the second or third 
week, one seventh or one fifth of the body weight in 
milk can be fed daily. At this time the water may be 
discontinued unless it is necessary to supply external 
heat of considerable degree, or the infant has a fever, 
both of which necessitate increased amount of fluids. 

FEEDINGS AFTER THE TWENTY-FIRST DAY 

Usually by the twenty-first day, the food require¬ 
ments of the infant are quite well established, and a 
careful observation of the infant’s weight, stools, dis¬ 
position and, equally important, its body temperature 
will decide the future requirements. 


FEEDING OF PREMATURE INFANTS 


61 


The water requirement will to a great extent be 
dependent on the supply of artificial heat and the 
presence of fever. Ordinarily by the beginning of the 
fourth week, from one seventh to one fifth (140 to 
200 c.c., or from 100 to 140 calories per kilogram) of 
the infant’s body weight in the form of breast milk 
is needed to maintain proper growth. Rarely is it 
necessary to exceed these amounts, even in the poorly 
nourished premature infant. If the physiologic func¬ 
tions are seemingly normal, the scale is the deciding 
factor in indicating food increases or decreases. 

As the infant takes on weight and becomes fat with 
a rounding of the features and the body, as is the case 
in premature infants successfully fed with breast milk, 
the total milk administration can be held at one sixth 
and not infrequently one seventh of the body weight, 
and normal weight increases may still be maintained. 

MIXED FEEDING 

When human milk, even though in small quantities, 
is available, it should form the basis of the diet, and 
cow’s milk mixtures should be supplemental. 

ARTIFICIAL FEEDING OF PREMATURE INFANTS 

A much higher mortality is to be expected when 
cow’s milk replaces human milk in the feeding of 
premature infants. 

When it becomes necessary to resort to artificial feed¬ 
ing, the quality of the cow’s milk and other ingredients, 
the preparation of the mixture, and the quantity to be 
administered must all be given careful consideration. 

Many different diets, such as simple milk dilutions, 
cream and skim milk mixtures, skim and buttermilk 
mixtures, malt soup preparations, condensed milk and 
evaporated milk, have been suggested. With each food, 
results are in large part dependent on the physician’s 
knowledge of the results that should follow its use. 


62 


PREMATURE INFANTS 


Ordinary milk, water and sugar mixtures are not 
well taken unless, by boiling or alkalizing the mixture, 
it is so modified that the curd becomes finely subdivided. 
Our best results have been obtained by the use of low 
fat and moderately high protein and carbohydrate 
mixtures. 

A boiled buttermilk or skim milk mixture 13 to which 
dextrinized flour and cane sugar are added may be used 
to advantage. For use during the first weeks it may be 
prepared according to the formula given in Table 2. 

The foregoing formula provides for 16 calories for 
each ounce, or 540 per liter. 

Table 2.— Mixture for Use During the First Weeks 


Buttermilk or skim milk.1,000 

Flour (dextrinized). 10 

Sugar (cane). 40 


For later use it may be prepared as in Table 3. 

All of the rules suggested for feeding with human 
milk must be rigidly observed both as to quantity and 
to frequency of feeding. In many instances it will be 
necessary to increase the diet even more slowly than 
suggested, and the infants must be carefully observed 
for evidence of overfeeding. It should also be evident 
that there is always great danger of underfeeding these 
infants when on an artificial diet. As soon as the 
infant’s condition warrants the fat-free diet, buttermilk 


13. The buttermilk and skim milk mixture is thus prepared: To a 
few tablespoonfuls of buttermilk or skim milk, 2)4 level tablespoonfuls 
of dextrinized Hour is added to make a paste. This is made up to 
1 liter with buttermilk. (1) The whole is brought to a boil, and with¬ 
drawn from the fire. (2) It is brought to a boil again, and withdrawn 
from the fire a second time. ( 3 ) Four level tablespoonfuls of cane sugar 
is added and the mixture is brought to a boil for the third time. This 
process should take about twenty minutes. The mixture should be stirred 
constantly with an egg beater while over the flame. It is made up to 
1 liter with boiled water, if the quantity has boiled away to a less 
amount. It is then put on ice. It is well to start with one-half the 
amount of sugar and increase as indicated, in the presence of loose 
stools. Maltose dextrin preparations may be used to replace the cane 
sugar. 










Fig. 7.—Gavage feeding: syringe barrel, catheter and graduated glass. 



















































ACCESSORY FOODS 


63 


or milk is to be replaced in part by whole milk, or small 
quantities of cream should be added. 

Cream can be added to the foregoing mixtures as 
indicated in Table 4. 

Whenever it is possible to obtain even small quantities 
of human milk, the artificial food should be used only 
to supplement the breast milk. 

Table 3. —Mixture for Later Use 


Buttermilk or skim milk.1,000 

Flour (dextrinized) . .. 15 

Sugar (cane). 60 


This formula provides for twenty calories per ounce 
or 700 per liter. 

Table 4. —Formula with Cream 


Buttermilk or skim milk. 950 

Cream, 16 per cent. 50 

Flour (dextrinized). 15 

Sugar (cane) ... 60 


Other Dietetic Requirements .—To counteract the 
effects of boiling, orange juice feeding should be insti¬ 
tuted by the third week, beginning with 0.5 c.c. (8 
drops) and increasing from 2 to 4 c.c. (from % to 
1 dram) daily by the eighth week, in order to avoid 
scurvy. Cod liver oil as an antirachitic should be fed 
by the fourth week, beginning with 0.5 c.c. (8 drops) 
daily, divided into two feedings and increased to 2 c.c. 
(30 drops) daily by the eighth week. It may be mixed 
with the orange juice. To counteract the low iron 
content of these diets, ferrous carbonate, 0.03 gm. 
(i/ 2 grain), or iron and ammonium citrate, 0.03 gm. 
(i/ 2 grain), once daily should be started by the fourth 
week. The latter may be prescribed in solution. 
















CHAPTER XII 


THE ARTIFICIAL FEEDING OF INFANTS 

A critical study of the work of the last fifty years in 
the artificial feeding of infants shows that the morbidity 
and mortality of infants has been definitely lowered. 
This has been brought about largely through a better 
understanding of the biology and chemistry of milk, 
and through applying to its collection and preservation 
the knowledge of the laws governing the incidence and 
growth of bacteria. 

The progress during the last decade in the artificial 
feeding of infants may be summarized in the statement 
that the one great step that has placed their feeding 
care on a sound basis is that their physiologic require¬ 
ments are now given first consideration. This has 
been made possible through a better understanding of 
individual needs in fat, protein, carbohydrates, salts, 
accessory food factors and water, to secure body 
growth and development. 

General rules may be laid down for the average 
full-weight and robust infant (fortunately, in the 
majority) who only requires supervision over his reac¬ 
tion to a properly balanced diet. But there remains 
a considerable number comprising (1) infants born 
congenitally weak, and (2) infants who have developed 
pathologic conditions secondary to food disturbances 
and infections. These will require the strictest indivi¬ 
dualization in the selection and application of their 
diets. 

If conclusions were drawn leading to the belief that 
our knowledge of artificial feeding is complete, great 
injustice would be done to the infant. Indeed, much 
is to be hoped for as our information on this subject 
advances, and this applies with equal force not only to 
the feeding of the exceptional and sick infant but also 
to the feeding of the normal child. 


HISTORICAL REVIEW 


65 


Laxity in the regulation of the feeding care of the 
infant during its first weeks is one of the greatest 
obstacles to a more complete success, for in this period 
the pathologic foundation is laid on which nutritional 
disturbances develop. The successful feeding of 
infants depends, therefore, on the recognition of the 
necessity of (1) a proper interpretation of the needs 
of the individual infant, and (2) experience on the part 
of the physician in meeting those needs. 

HISTORICAL REVIEW 

Very few records on the subject of infant feeding 
are available 15 antedating the fifteenth century. The 
first of these, issued in 1487 by Paulus Bagellardus, 
was entitled “De Aegritudinibus Infantum.” The 
earliest book in English appeared in 1567, when Thomas 
Faier published “The Regimen of Life.” During the 
eighteenth century a dozen or more books appeared. 
The output doubled in the first half of the nineteenth 
century. Artificial feeding, for example, as a substitute 
for the breast is not mentioned until the eighteenth 
century. Breast feeding was practically the only means 
of nourishing a young child. The infant had no choice 
but the breast either of its mother or of a wetnurse. 

Bagellardus says that the mother (or wetnurse) 
customarily suckled her child for two or three years. 
Even in those days mothers, like many of their modern 
sisters, found that nursing interfered with their social 
duties, and those who could afford them were glad 
to shift their maternal duties to hired wetnurses or 
foster mothers. It is hard to realize in this day, when 
wetnurses are few and far between, how widely they 
were in demand in previous generations. 

Infant deaths were common enough from natural 
causes. Yet artificial feeding, which is one of the 


15. Mixsell, H. R.: Arch. Pediat. 33:282 (April) 1916. 



66 


ARTIFICIAL FEEDING 


most prolific causes of disease and death, was not 
practiced. With unclean houses and insanitary towns, 
hand feeding was still a deadly undertaking. Infant 
mortality was high, two fifths of the total deaths being 
of children under 2 years of age. During some years 
more than half the children born were lost from 
infantile diseases. No mention is made of artificial 
feeding, so that it cannot be blamed for this death rate. 

Early in the eighteenth century, changes were in 
progress. If the mother could be supplanted, why not 
the wetnurse? Why not employ some other food than 
human milk? It was finally considered safe, about the 
middle of the century, to give water-pap as soon as 
the first tooth had appeared. Cow’s milk was still 
objected to. The breast was not withdrawn altogether 
until the child was 2 years old. In the literature about 
this time appear the first recommendations for the use 
of cow’s milk for supplemental feeding. 

In a treatise entitled “On the Raising of Healthy 
Infants,” published by J. P. Frank, in 1749, we read 
that von Swieten, Loseke and Cosner were the first 
to advocate diluted cow’s milk for infant feeding. 
Frank advised dilution with either plain water, barley- 
water, wheat-water or oatmeal-water. 

Ass’s milk and animal broths seem to have had early 
use. John Armstrong, in “An Account of the Diseases 
Most Incident to Children,” (London, 1783), recom¬ 
mends that the nursing child should take, in addition 
to the breast, pap or panada made from bread-crumbs 
boiled in water and sweetened with sugar. If the child 
was artificially fed from the start, it should have “cow’s 
milk mixed with its victuals as often as possible and 
now and then a little of it alone to drink. Ass’s milk 
will be still better.” If the milk disagrees, he says, 
animal broths should be given. To assist teething and 
to promote the secretion of the salivary glands, a crust 


MICHAEL UNDERWOOD’S BOOK 


67 


of bread dipped in water or milk should be given to 
the child to suck. 

Among English writers the next advance in methods 
of feeding is found in John Clarke’s “Commentaries on 
the Diseases of Children” (London, 1815). This 
author was one of the first to advocate the employment 
of cream diluted with starchy concoctions; he also 
seems to have used whey as a beverage. 

Michael Underwood, in his admirable (for the 
period) “Treatise on the Diseases of Children,” which 
ran into ten editions (1811-1847), although influenced 
by hoary traditions, still endeavors to free himself 
from the prejudices of the age. He is the first who 
seriously attempted to find some substitute for breast¬ 
feeding. 

In the edition of 1818 he says: 

It has, indeed, been universally lamented, that in no age 
has the study of the disorders of children kept pace with the 
advancement of science. Indeed, till of late years, little 
more has been attempted than getting rid of the wild preju¬ 
dices and prescriptions of the old writers, which had served 
only to obscure the true nature of children’s diseases. A 
very principle cause of the above-mentioned neglect has 
arisen from an ancient idea, for a long time too generally 
entertained, that, as medical people can have but a very 
imperfect knowledge of the complaints of infants, from the 
inability of children to give any account of them, it is safer 
to trust the management of them to old women and nurses, 
who, at least, are not likely to do mischief by violent reme¬ 
dies, though they may sometimes make use of improper and 
inadequate ones. 

Recognizing the importance of choosing a milk as 
near as possible to mother’s milk, he includes in his 
treatise two comparative analyses of the milk of 
women, cows, goats, asses, sheep and mares. The 
conclusions that he draws are that cow’s milk is best 
suited for the ordinary case, but for the very young 
or in bad cases of diarrhea ass’s milk is to be used, 


68 


ARTIFICIAL FEEDING 


as it is thinner and has far less curds than other milks. 
To this milk a diluent of barley water is suggested as 
an addition. This is the beginning of milk dilution, and 
marks another decided step in advance. Some years 
later other diluents besides barley were mentioned, the 
one most advocated being a small quantity of light 
jelly made from hartshorn shavings, boiled in water 
to the consistency that veal broth acquires when cold. 
To this was added a little Lisbon sugar, or loaf sugar. 

The design of the jelly is obvious and rational, at once 
calculated to render the food more nutritive, as well as to 
correct, in some measure, the ascendency of the milk; this 
quality being thought to abound in the milk of different 
animals, in proportion to the quality of vegetables on which 
they feed. And the milk of quadrupeds, we know, is pro¬ 
duced from vegetable juices only, while breast milk is formed 
by a mixture of animal and vegetable food. A little Lisbon 
sugar may be added to this compound of jelly and milk if 
the child be not inclined to a purging, or in that case a little 
loaf sugar, but the less of either the better. At first the 
milk ought to be boiled, to render it less opening; but when 
the child is several months old, or may chance to be costive, 
the milk need only be warmed. If it be fresh from the cow, 
and very rich, a portion of water may be added to it, whilst 
the infant is very young. Indeed, it ought to be as new as 
possible, since milk, as an animal juice, probably contains 
some fine subtile particles, which evaporate upon its being 
long out of the body. 

Though I have said cow’s milk is usually preferable to 
any other, it will be conceived that I mean for infants who 
are strong and healthy. Ass’s milk, on the other hand, being 
more suitable for many tender infants during the first three 
or four weeks, or perhaps for a longer time, as well as for 
children who are much purged; as it is thinner and having 
far less curd than any other milk, it sits much lighter on 
the stomach, both of tender infants and adults. 

Writing during this same period, Marriman states 
that “the attempt to bring up children by hand proves 
fatal to seven out of eight of these miserable sufferers; 
and this happens where the child has never taken the 


EARLY INFANT MORTALITY 


69 


breast, or, having been suckled for three or four weeks 
only, is then weaned.” 

For the diet of older children, Underwood gives 
broths, beef-tea, puddings made of bread, semolina, 
tapioca (new at the time), or rice and salep boiled 
in milk. Later he gives light meats, vegetables and 
“red wine” to counteract the tendency to rickets. All 
these during the first year in many cases. The weaning 
period was held to be about twelve months, or when 
the child had cut at least four teeth. 

As infant feeding and infant mortality are so closely 
bound up together, the records of infant deaths should 
throw some light on the subject. From 1780 to 1816 
(Forysthe), in London, there were 56,000 births and 
19,000 deaths under 2 years of age, or approximately 
34 per cent. Of these the mortality was 80 per cent, 
hand-fed, or seven out of eight. The Paris Foundling 
Flospital had a mortality of 85 per cent, of 32,000 
infants, while in Dublin, of 10,000 children admitted 
to the hospitals during the years 1775 to 1796, only 
forty-five survived—in other words, 99.6 per cent, died 
—a simply frightful mortality. It is therefore plain 
why artificial feeding was regarded with such suspicion, 
and why it made such little headway. 

The infant mortality of the time in America ran 
almost parallel to the European figures, being, if any¬ 
thing, less, owing probably to the outdoor life. Medical 
instructions to physicians gave but little help to the 
mothers, and the feeding of the infant was carried on 
haphazardly and on no scientific basis. 

Dewees, writing in 1832, recognized the value of the 
application of heat to prevent decomposition of the 
milk, but advised against prolonged heat at a tempera¬ 
ture at or above boiling: 

Boiling takes from the milk some of its best qualities. In 
hot weather, it is true, the tendency to decomposition is 


70 


ARTIFICIAL FEEDING 


diminished by boiling the milk. It is every way sufficient 
for the purpose of preservation that the milk be put closely 
covered over a hot fire and brought quickly to the boiling 
point; so soon as this is perceived, it should be removed 
and cooled as speedily as possible. By this plan we prevent 
in great part the formation of that strong pellicle which is 
always observed on the top of boiled milk, and by which the 
milk is deprived of one of its most valuable parts. 

It was not until reorganization of the New York 
Medical College in 1860 that a special clinic for the 
diseases of children was opened. It was due to the 
efforts of Abraham Jacobi, the dean of pediatricians in 
this country, that this was brought about. Other 
medical colleges quickly followed suit, and by 1870 
pediatrics and infant feeding in particular finally began 
to be placed on a scientific basis. 

In 1858, Cummings 16 gave a clear exposition of 
what might be termed the forerunner of percentage 
feeding. But it was not until Biedert’s work, pub¬ 
lished in 1869, that.the real foundation for modern 
infant feeding was laid. Prior to this, most of the work 
was empiric, and the results obtained in substituting 
artificial for breast feeding were bad. Biedert’s com¬ 
parative analysis first proved that the protein of breast 
milk is less than half of that contained in cow’s milk, 
and is of different quality. As a result of his labora¬ 
tory and clinical investigations, he taught the basic 
idea that the casein of cow’s milk when fed in large 
quantities resulted in digestive disturbances. He fed 
mixtures very low in casein, but with high fat and 
whey content. 

John Forsyth Meigs, in 1885, enlarged on Biedert’s 
work, believing, as did Biedert, that the casein in the 
milk caused much of the trouble in infant feeding. 
He further emphasized the need for a better knowl¬ 
edge of the amount of cream, sugar and lime water 


16. Cummings: Am. J. M. Sc. 36:25, 1858. 



EARLY METHODS OF FEEDING 


71 


to be added in his modification in order that the com¬ 
position of human milk might be approached. This, 
in fact, was the real basis for the percentage method, 
which Thomas Rotch (1887) later developed and 
refined. Rotch believed that for the successful feeding 
of infants the modifications should be so gaged that 
they could be changed to meet special indications. He 
was the first to emphasize the need of individualization 
and to show the necessity of fully considering all of 
the food elements in the diet. He taught us that fat 
and sugar, as well as protein, were important factors 
in the disturbances of artificially fed infants. His 
work on percentage feeding, that is, increasing or 
decreasing the various constituents of human milk to 
meet definite clinical conditions, was probably the first 
epoch-making advance in infant feeding, and his sys¬ 
tem has since been known as the percentage method. 

Following the teachings of Jacobi, Meigs and Rotch, 
the further development of scientific infant feeding 
was for many years essentially American. Possibly 
the chief criticism that can be offered on the early 
feeding methods is that, as shown in the light of later 
experience, too great consideration was paid to the 
food itself, more especially to its casein content, and 
too little to the infant. Notwithstanding this, these 
early careful investigations greatly aided in lowering 
infant mortality. 

The German school, of which Rubner and Heubner 
were the chief advocates, brought forward the so-called 
“caloric method” of feeding, by which they sought to 
provide the number of heat units required by the 
infant, basing their estimations on the infant’s weight. 
This method will be discussed later. We do not now 
use this method, but a check on the caloric content 
of the food is of inestimable worth in determining the 
value of our mixtures, for avoiding overfeeding and 


72 


ARTIFICIAL FEEDING 


underfeeding. The German school has never attempted 
such refinements in the percentage composition of their 
mixtures as are advocated by the American school. 

More recently, Czerny and Finkelstein have empha¬ 
sized the dangers of overfeeding with whole milk, 
and also with its individual ingredients, fat, sugar and 
salts, separately or in combination. Their studies have, 
on the whole, ignored the proteins, probably because 
protein disturbances other than those seen in infants 
suffering from a milk idiosyncrasy mostly occur in 
infants fed on raw cow’s milk, while the greater 
number of the continental clinics have for several years 
fed boiled milk. Their studies and conclusions will be 
more fully reviewed in the discussions of the distur¬ 
bances of artificially fed infants. 

In American clinics during the last few years, there 
has been an increasing tendency toward boiling cow’s 
milk before feeding it to the infant. This is in order 
to make the curd more fragile, and to destroy the 
pathogenic bacterial content of the milk as well. While 
this method has many advantages, it must not be over¬ 
looked that boiling causes definite changes in the milk, 
more especially as regards the soluble albumins, fer¬ 
ments and vitamins, which are of essential importance 
to the human economy. Fortunately, these can largely 
be overcome by the early administration of fruit and 
vegetable juices, nondextrinized cereals and other 
foods, such as cod liver oil. 


CHAPTER XIII 


COW’S MILK AND GOAT’S MILK 

It cannot be too strongly emphasized that artificial 
feeding must not be considered as a substitute for 
breast feeding but only as an emergency measure. The 
best alternative is feeding with properly modified milk 
of other animals, and, for practical reasons, cow’s milk 
and goat’s milk have been found best suited for this 
purpose. Because of the marked chemical, physical 
and biologic differences between human milk, and cow’s 
and goat’s milk, human milk is superior to the others 
in infant feeding. The differences are greater than 
Table 5 indicates. 

Table 5. — Comparative Analysis of Breast, Cow's and 

Goat’s Milk 


Human Cow’s Goat’s 


Reaction Amphoteric Amphoteric 

or Alkaline or Acid Amphoteric 

Specific gravity.1.010 to 1.040 1.029 to 1.034 1.030 

Proteins. 1.5 to 2.0% 3.5% 3.76% 

Caseinogen . 0.5 to 0.75% 3.02% 2.87% 

Lactalbumin . 1.23% 0.53% 0.89% 

Effect of rennin. Clots in fine Large curds Large curds 

curds 

Fat . 3.5 to 4.0% 4.0% 4.0% 

Lactose. 6.0 to 7.0% 4.5% 4.5% 

Salts. 0.2% 0.75% 0.85% 

Total solids. 12 to 13% 13 to 14% 13.0% 

Water. 86 to 88% 86 to 87% 86 to 87% 

Bacterial content. Practically Never sterile Never sterile 

sterile 


cow’s MILK 

Cow’s milk is more opaque than human milk, 
although the latter may contain a greater percentage 
of fat. This is due to the opacity of the calcium-casein, 
present in greater proportion in cow’s milk. Cow’s 
milk is faintly acid or amphoteric when freshly drawn, 
but ordinarily is distinctly acid in reaction when con¬ 
sumed. Human milk is amphoteric or alkaline. 
















74 


COW’S MILK AND GOAT’S MILK 


Three times as much protein is found in cow’s milk 
as in human milk. The reason for this is obvious 
when we recall that the ratio of growth of the calf to 
that of the infant is about as 2:1. Furthermore, the 
protein in cow’s milk consists chiefly of casein (3.02 
per cent.) and a little lactalbumin (0.53 per cent.), 
while human milk contains from 0.5 to 0.75 per cent, of 
casein and 1.23 per cent, of lactalbumin. The sugar in 
the two milks varies greatly in amount but not in kind. 
Cow’s milk contains more than three times the amount 
of inorganic salts in human milk. 

Infants on whole cow’s milk, therefore, live on a 
higher plane of mineral metabolism than infants on 
breast milk. Owing to a similar proportionate content 
of salts in the two milks, simple dilution, while equaliz¬ 
ing most of the salts, will leave others either in excess 
or insufficient. Fortunately, excessive amounts of milk 
salts are rarely harmful to normal infants, as those in 
excess of the body needs are excreted. The greater 
danger lies in mineral starvation or a diet improperly 
balanced in its mineral content. The importance of 
salts to body function and growth in the artificially fed 
infant will be considered later in detail. 

There is no great difference in the average amount 
of fat in the two milks; however, both in human milk 
and in cow’s milk fat is the most variable constituent. 

The curd from cow’s milk is usually tougher and 
forms in larger masses than in human milk. There are 
also differences in antibodies, ferments, etc. 

Protein .—The protein in cow’s milk consists of inso¬ 
luble calcium caseinate and soluble lactalbumin, lacto- 
globulin, mucin and opalisin. Of these, the casein 
(85 per cent.) and lactalbumin (15 per cent.) form the 
greater part of the protein content, the others existing 
in negligible quantities. 


CASEIN AND FATS 


75 


Casein .—This is in suspension, and is rapidly pre¬ 
cipitated by weak acids and by rennin, but it is not 
coagulated by boiling. The casein of raw cow’s milk 
precipitates as large, tough curds, thereby differing 
from the fine, flocculent curd of human milk. The 
physical properties of cow’s milk curds can be changed 
by boiling the milk, and by adding alkalis, such as 
sodium citrate, sodium bicarbonate and lime water. 
Following such additions, the curd becomes finely 
divided, resembling the curds of breast milk. By the 
addition of cereal water in the milk dilution, a similar 
effect is obtained through the mechanical fragmentation 
of the curd by the interspersed starch particles. Split¬ 
ting of the curd shortens the period of digestion, the 
finer curds passing the pylorus more readily, which 
brings them in contact with the intestinal juices in 
a shorter time. 

Lactalbumin .—This is not coagulated by acids or by 
rennin, but is coagulated by heating to 72 C. or higher. 

Fats .—The fat is suspended in the milk serum as 
an emulsion. The droplets or globules vary in size; 
on the average, they are smaller in milk from Holstein 
than from Jersey, Guernsey or shorthorn breeds. The 
fat droplets are lighter than the milk serum and there¬ 
fore rise on standing (gravity cream), or they may 
be readily separated by centrifugal force (centrifugal 
cream ). The chemical composition of the fat of cow’s 
milk differs from that of human milk in that it con¬ 
tains more tripalmitin and less triolein. This difference 
is of practical importance, since the calcium and mag¬ 
nesium soaps of palmitic acid are much less readily 
absorbed from the intestinal tract than are the soaps 
of oleic acid. Cow’s milk also contains a considerable 
proportion of glycerids of the lower or volatile fatty 
acids, which under certain circumstances may irritate 


76 


COW’S MILK AND GOAT’S MILK 


the intestinal tract, resulting in diarrhea. Not only is 
there difference in the size of the fat droplets from 
certain breeds of cattle, but the average total fat 
content varies very materially. The average fat content 
for different herds as given by Van Slyke and Publow, 17 
is reproduced in Table 6. 

Lactose .—This is the principal sugar in both cow’s 
and human milk, its chemical composition in the two 
being identical. Average human milk contains from 
6 to 7 per cent., and cow’s milk from 4 to 5 per cent. 
The larger sugar content of human milk, with its fer¬ 
mentation, accounts for the laxative effect of breast- 
milk feeding when the milk is abundant. 

Table 6. —Fat Content of Milk of Various Herds 


Breed 

Holstein-Friesian . .. . 

Ayrshire . 

American Holderness 

Shorthorn . 

Devon . 

Guernsey . 

Jersey . 


Fat Percentage 

_ 3.26 

- 3.76 

_ 4.01 

_ 4.28 

_ 4.89 

_ 5.38 

_ 5.78 


Salts .—Salts are necessary in digestion and in every 
step of metabolism, from absorption to secretion and 
excretion. The role of salts in both normal and patho¬ 
logic conditions has assumed increased importance 
under the investigative studies of the last few years. 

Human milk contains 0.2 gm. of ash in 100 c.c., and 
cow’s milk 0.75 gm. The difference in percentage in 
human and in cow's milk is equalized, as the body uses 
only what is necessary for its life and growth. 

All the salts except those of iron are in larger 
amounts in cow’s than in human milk. Cow’s milk 
contains relatively a very large amount of calcium 
phosphate, while the amount of iron in cow’s milk is 
less than that in human milk. Human and cow’s milk 


17. Van Slyke and Publow, quoted by Heineman (Footnote 24). 














SALTS IN MILK 


77 


differ greatly in the form of the phosphorus content. 
In human milk, three quarters of the phosphorus is 
in organic combination, while in cow’s milk only one 
quarter is so combined. Neither in human nor in 
cow’s milk is the iron content sufficient to meet the 
demands in the first year of life; the infant must 
depend on the iron stored during the fetal life. 

The percentages and grams of the different salts of 
human and cow’s milk, as found in 100 parts of ash, are 
given in Table 7. 

Table 7. — Salts of Human and of Cow’s Milk 



AVERAGE PERCENTAGES 

OF DIFFERENT SALTS IN 

THE 

ASH 




CaO 

MgO 

P 2 0 5 Na 2 0 

k 2 o 

Cl 

Fe 

Human 

milk. 


23.3 

3.7 

16.6 7.2 

28.3 

16.5 

0.00015* 

Cow’s 

milk. . 


23.5 

2.8 

26.5 7.2 

24.9 

13.6 

0.00007* 

GRAMS OF 

SALTS FOR 

EACH 

HUNDRED CUBIC 

CENTIMETERS 

OF MILK 



CaO 

MgO 

P 2 0 

s Na,0 

k 2 o 

Cl 

Fe 

Human 

milk. 

0.0458 

0.0074 

0.0345 0.0132 

0.0609 

0.0358 0.00017* 

Cow’s 

milk.. 

0.172 

0.02 

0.2437 0.0465 

0.1885 

0.082 

0.00007f 


* Holt, L. E.; Courtney, A. M., and Fales, H. L.: A Chemical Study 
of Woman’s Milk, Especially Its Inorganic Constituents, Am. J. Dis. 
Child. 10:229 (Oct.) 1915. 

t Langstein and Meyer: Sauglingsernahrung und Sauglingsstoss- 
wechsel, Wiesbaden, J. F. Bergman, 1914, p. 22. 

In all the constituents except phosphorus pentoxid 
and iron, the percentages of the different salts in the 
two milks are practically the same. The higher pro¬ 
portion of phosphorus in cow’s milk is due to the large 
amount of casein. While the proportion of salts in 
cow’s milk is nearly the same as in human milk, the 
amount is about three times as great. Unless, therefore, 
cow’s milk has been diluted with more than twice 
its volume, these inorganic constituents are furnished 
to the infant in equal proportion to that in human milk 
(Holt). Human milk contains about twice as much 
iron as cow’s milk, and dilution of cow’s milk results 
in a decrease in the iron content which must not be 
carried too far unless supplemented by other iron- 
containing food. 







78 


COW’S MILK AND GOAT’S MILK 


Ferments. —Cow’s milk contains a number of fer¬ 
ments, but little is known of their value to the infant. 
Escherisch and Hamburger thought that they had a 
favorable influence on the processes of metabolism. 
Salge discovered that tetanus and diphtheria antitoxins 
could be utilized by the infant only when found in 
human milk, while when contained in the milk of 
other species they did not get into the body fluids. 

Vitamins. —Cow’s milk contains fat-soluble A in 
considerable quantity, and water soluble B and C in 
lesser amounts. 

Bacterial Content. —The bacteria of cow’s milk vary 
in kind and number, depending on the conditions under 
which the milk is collected, preserved and handled. 
While human milk may be either sterile or have a low 
bacterial content, cow’s milk is never sterile, and only 
too frequently, through carelessness, the original flora 
multiply rapidly. Certified, pasteurized and sterilized 
milk was the practical outcome of the efforts made 
to obtain germ-free milk for infant feeding. 

The harmful or undesirable micro-organisms occur¬ 
ring in milk are of two classes. (1) Those that are 
definitely pathogenic and capable of producing infec¬ 
tious disease. Examples are the typhoid and dysentery 
groups, the tubercle bacilli, the virus of scarlet fever 
and Bacillus abortus . 18 (2) Saprophytic bacteria, 
some of which decompose milk and form products 
capable of causing gastro-intestinal disturbances. 

Of the nonpathogenic organisms, those most fre¬ 
quently found are the lactic acid-producing bacteria. 
The most common types are: Streptococcus lacticus, 
Bacillus lactis-acidi, B. Lactis-aerogenes, B. bulgaricus, 
B. acidophilus and B. bifidus. The micro-organisms 
producing only lactic acid are mostly harmless, and the 

18. Fleischner, E. C., and Meyer, K. F.: Bacillus Abortus, Bovinus 
in Certified Milk, Am. J. Dis. Child. 14: 157 (Sept.) 1917. 



BACTERIA IN MILK 


79 


lactic acid itself in the amounts produced in milk does 
not cause diarrhea when fed. In fact, the production 
of lactic acid leads to the destruction of many of the 
more harmful varieties of bacteria in milk. 

The butyric acid group is also frequently present. 
This group produces butyric acid by its action on 
sugar and fat. Another group frequently found in 
milk are the proteolytic bacteria, which coagulate 
the milk and may cause a further splitting of the 
protein. Bacillus coli, which, as well as others, has 
the property of producing lactic acid; B. proteus, 
B. alkaligenes, the hay bacillus, B. aerogenes-capsulatus 
and others belong to this group. Most of the latter are 
sporebearing. 

Slime-forming bacteria occasionally invade the milk. 
Among the most tenacious of these is B. lactis-viscosi. 
Streptococcus lacticus occasionally causes similar 
changes. At times the milk becomes bitter, because of 
the formation of peptones by contaminating organisms. 
Certain vegetables and plants may cause a similar taste 
in the milk. Occasionally a milk of reddish color is 
seen. This may be due to blood from the udder, or 
to the action of B. prodigiosus. A blue milk is even 
more common, and is due to B. cyanogenes. Protein 
and carbohydrate splitting yeasts and molds not infre¬ 
quently invade the milk and cause changes that become 
more evident as the milk grows older. 

goat’s milk 

Goat’s milk is pure white, without especially pro¬ 
nounced odor or taste. There may be a peculiar “goaty” 
taste and unpleasant odor to the milk, but this can be 
entirely avoided if the milk is properly produced and 
handled, that is, by preventing manurial pollution, by 
keeping male goats out of and away from the stable 
in which the milking is done, and by taking precautions 
to keep the udder clean. 


80 


COW’S MILK AND GOAT’S MILK 


There is no essential chemical difference between the 
constitution of goat’s milk casein and that of cow’s 
milk. 19 The casein coagulum forms a more compact, 
firm mass than does that of the bovine. 

Because of the similar chemical composition, goat’s 
milk may be modified, like cow’s milk, for infant 
feeding. 20 The protein content is considerably higher 
than in human milk, the sugar considerably less. The 
fat varies from 2.5 to 7.5 per cent., 21 generally a 
little higher than that in cow’s milk. The butter fat is 
white, there being a minimum of pigment. 22 The 
fat rather closely resembles the fat in human milk. 
The fat globules are relatively small, in very fine drop¬ 
lets, 23 and of uniform size. Ninety per cent, of the 
fat globules of cow’s milk are over 4 microns in 
diameter; in goat’s milk only about 10 per cent, are 
over 4 microns, and often 50 per cent, are under 
2 microns. 

The fat globules rise slowly, and in most cases no 
cream layer is formed. The cream is separated with 
difficulty by centrifuging, 24 but may be thoroughly sepa¬ 
rated in a cream separator. Goat’s milk fat is richer in 
insoluble volatile acids than cow’s milk fat; but, on the 
whole, there is very little difference when the chemical 
composition of the two fats is compared. 25 

In regard to the salt content, goat’s milk differs 26 
from cow’s in containing tricalcium phosphate, dimag¬ 
nesium and trimagnesium phosphate, monopotassium 
phosphate, and no monomagnesium or dipotassium 
phosphate. Human milk contains no insoluble phos- 

19. Calvin, J. K.: Arch. Pediat. 3S: 584 (Sept.) 1921. 

20. Griffith: Diseases of Infancy and Childhood 1: 109, 1919. 

21. Vieth: Milchztg. 14:449, 1885. 

22. Schaffer: Schweiz. Wchnschr. f. Pharra. 31:58. 

23. Barbellion: Verhandl. f. Kinderh. 13, 1900. 

24. Heineman, P. G.: Milk, Philadelphia, W. B. Saunders Company. 
1920. 

25. Solberg: Jahrb. f. Thierchem. 25:214. 

26. Bosworth and Van Slyke: J. Biol. Chem. 24: 173, 177 (March) 
1916. 



GOATS 


81 


phates. Goat’s and cow’s milk contain more phosphorus 
than human milk. There are more chlorids in goat’s 
than in human or in cow’s milk. The different salts 
appear to be greatest in number in goat’s and least 
in human milk. McLean 27 asserts that goat’s milk 
contains more iron than cow’s milk. 

Yield .—In proportion to its body weight, the goat 
produces about twice as much milk as the cow. The 
goat may yield from ten to twelve or even fifteen 
times its body weight in milk yearly, while a cow yields 
five or six times its weight. 28 By good feeding, 800 
kg. or more (from 600 to 1,100 liters) of milk may 
be obtained in a year. A year-old goat will produce 
from 300 to 700 liters a year. 29 Goats usually provide 
milk about six months out of a year, and a lactation 
period ranging from seven to ten months is considered 
very satisfactory. A good scrub or common goat 
will yield about 2 quarts (liters) of milk a day, 30 and 
a production of 3 quarts a day is considered excellent. 
However, a good grade Toggenburg will produce 
from 3 to 4 quarts, and some pure-bred Toggenburgs 
will run from 5 to 7 quarts a day. 

If goat’s milk is aseptically obtained, it is the most 
suitable substitute for breast milk, since it has not 
been exposed to the possibility of changes, has not 
lost its natural properties, and can be given raw. 

Another advantage of goat’s milk is that it cannot be 
skimmed, as the cream does not form a distinct layer. 31 

Goats are practically immune to tuberculosis. 32 Only 
from 0.4 to 0.6 per cent, of the goats in Prussia gave 
a positive reaction for tuberculosis. 24 The question 

27. McLean: Ztschr. f. Kinderh., Orig. 4:168, 1912. 

28. Fleischman: Lehrbuch der Milchwirthschaft 2 : 65, 1898. 

29. Kohlschmidt: Jahrb. f. Thierchem. 30: 254, 1901. 

30. Rosenau: The Milk Question, New York, Houghton, Mifflin Com 
pany, 1912. 

31. Kochen: Steinegger, Milchztg. 27: 356, 1898. 

32. Richter: Berl. klin. Wchnschr., 1888, No. 18. 



82 


COW’S MILK AND GOAT’S MILK 


of the transmission of a passive immunity to tuber¬ 
culosis by the transfer of natural antibodies from goat’s 
milk to very young infants, or from the use of this 
milk over a much longer period, is now being investi¬ 
gated. At present the results are incomplete. 

From some very limited data it might appear that 
goat’s milk is considerably higher in antiscorbutic 
properties than cow’s milk. Moore states that six 
guinea-pigs weighing from 110 to 145 gm. each were 
fed on fresh goat’s milk, one set for eighty days, a 
second for forty-four days. The animals developed 
normally with no clinical symptoms of scurvy, although 
similar experiments with cow’s milk resulted in scurvy. 

CERTIFIED MILK 

The term “certified milk” should be limited to milk 
produced in accordance with the requirements of the 
American Association of Medical Milk Commissions. 33 
The expressed desire of the dairyman to contract to 
produce clean milk is far from sufficient for public 
protection. Only by periodic inspection by representa¬ 
tives of the local authorities, such as city, state or 
special commissioners, can a supply of wholesome milk 
be continuously assured. Sanitary stables and proper 
handling of the cows, with milking into sterilized 
receptacles are prime essentials. The cows must be 
in good health, free from tuberculosis and other infec¬ 
tious diseases. All persons coming in contact with 
the milk must exercise scrupulous cleanliness and must 
be free from infections which might be conveyed to 
others through the milk. All of these precautions can 
be nullified by carelessness in handling the milk, either 
at the farm, during transportation or in the home. 

Certified milk must have a minimum bacterial content, 
■ ■ - — - .... ■■■ — ■■■ ■ ■ ■ ■ ■■ ■■ ■ -■ . 

33. The standards are given in the literature of the American Associa¬ 
tion of Medical Milk Commissions. 



CERTIFIED MILK 


83 


and should never be more than thirty-six hours old 
when delivered. 

Certification must be denied all milks having, on 
repeated examination, a bacterial count exceeding 
10,000 per cubic centimeter. Such examination should 
be made at least once a week. Of even greater impor¬ 
tance than the number are the types of bacteria found 
in the milk. The milk from all sick cattle and those 
with open wounds must be excluded. Employees suf¬ 
fering from infectious diseases which may contaminate 
the milk must be quarantined, and if contagious dis¬ 
eases occur on the premises of a certified dairy, the 
customers should be notified so that the milk may be 
sterilized in the home if the commission shall deem 
it wise to allow the milk to be delivered. In case of 
doubt, the dairy should be temporarily stopped from 
further deliveries. The milk must be cooled immedi¬ 
ately after being secured, and maintained at a tempera¬ 
ture between 35 and 40 F. until delivered. 

Many good milks are spoiled on the door-step of 
the home between the time of delivery and of placing 
the milk in the icebox. All the utensils and vessels 
used for preparing the mixture must be clean and 
sterilized by boiling. As soon as the mixture is pre¬ 
pared, it should be put into the icebox again and kept 
there, preferably in individual bottles containing single 
feedings. 

PASTEURIZED MILK 

Pasteurization is accomplished by heating milk for 
a definite length of time, varying according to the tem¬ 
perature to which the milk is heated. The “holding 
method” whereby the milk is heated to not less than 
from 140 to 150 F., (60 to 65 C.) and is kept at this 
temperature for at least twenty minutes, is probably the 
most efficient for commercial purposes. Pasteurization 
in the home is well accomplished by one of several sim- 


84 


COW’S MILK AND GOAT’S MILK 


pie pasteurizers obtainable in the market. Similar 
results may be obtained by placing milk in the inner 
vessel of a double boiler with cold water in the outer 
vessel. The water is then heated to 160 F., and the 
milk is allowed to stand in its receptacle in a warm 
place for twenty minutes, following which it is rapidly 
cooled in a good icechest, where it should be kept until 
the time for reheating at feeding periods. If a similar 
method is desired for pasteurization in individual bot¬ 
tles, they should be placed in a pail, and water added to 
a level above the milk contained in the bottles, after 
which the water is heated to 160 F. The pail is then 
removed from the stove, covered, and kept in a warm 
place for one-half hour, after which the milk is to be 
rapidly cooled in a good icebox. It should be remem¬ 
bered that the bottles must be properly stoppered. 

i 

Scalded Milk .—The milk is heated in an open vessel 
until it bubbles around the edges and steams in the 
center. By this means it is heated to temperatures 
varying from 165 to 185 F. Scalding is not boiling. 

Boiled Milk .—Milk may be boiled in either a single 
or a double boiler. With a single boiler, the milk is 
heated to the boiling point and allowed to boil from 
three to five minutes, with constant stirring. With a 
double boiler, the milk mixture in the inner and cold 
water in the outer vessel, the water is brought to the 
boiling point and kept boiling for from six to eight 
minutes; the whole process requires from ten to twenty 
minutes. Following the heating, cold water should be 
substituted in the outer vessel, and should be renewed 
several times until the milk cools. The milk is then 
put in small sterilized bottles for individual feedings, 
or in one large bottle, capped, and placed on ice. While 
milk heated in a double boiler forms a much finer and 
softer curd than that of raw milk, it is not so fine as the 
milk boiled directly over the flame. It does, however, 


BOILED AND RAW MILK 


85 


answer the needs in most cases, and, because of the 
simplicity of the method, is preferable. 

RAW MILK VERSUS HEATED MILK 

Whatever opinion one may have as to the advisability 
of recommending heated milk rather than raw milk for 
infant feeding as a general practice, it must be recog¬ 
nized that the earlier teaching in America concerning 
raw milk feeding led to the production of certified milk, 
with a resulting decrease in infant mortality. How¬ 
ever, it should be emphasized that any method of food 
preparation which may tend toward an erroneous feel¬ 
ing of security is to be avoided. This applies par¬ 
ticularly to milk production, as it is obvious that 
unclean milk cannot be considered a safe food for 
infants, even though it is pasteurized or boiled. 

Razv Milk .—In large communities, certified milk 
from properly inspected dairies is the only milk which 
may be fed raw with any feeling of safety. During the 
warm months, even certified milk should be pasteurized 
or boiled in the home. In small communities, when 
the milk has been produced under sanitary conditions 
and reaches the home a few hours after milking, it may 
be safely used. When there is any doubt as to the 
quality of the milk, it should be heated. 

PASTEURIZATION VERSUS BOILING 

The ardent advocates of pasteurization claim that it 
is essentially a raw milk, so far as concerns its physi¬ 
ologic properties. Our experimental studies have 
shown that when milk is allowed to stand for some 
time after pasteurization, even though the vitamins are 
not completely destroyed, its antiscorbutic value is less 
than that of fresh raw milk. Therefore the relation 
of the time of pasteurization to the hour of feeding is 
important. Proper pasteurization destroys most organ- 


86 


COW’S MILK AND GOAT’S MILK 


isms except the spore bearers. Fortunately, this 
includes the majority of the ordinary pathogenic 
bacteria. One disadvantage is that most of the lactic 
acid-producing bacteria are destroyed, and, therefore, 
the milk fails to sour, or sours less readily than 
unheated milk. This may give the mother a false feel¬ 
ing of security. In most instances, however, some of 
the lactic acid-producing organisms, having a high 
thermal death point, survive the heating and thereby 
lead to souring in old milk. While commercial pas¬ 
teurization, therefore, has its disadvantages, on the 
whole its use has accomplished much in the lowering 
of infant mortality. 

Boiling in the Home .—This has the great advantage 
over commercial pasteurization in that if the raw milk 
has soured before it reaches the home, the housewife 
can readily detect it. However, it is to be remembered 
that many pathogenic organisms may develop in milk 
without giving any evidence of their presence; and, 
while the organisms themselves are in most instances 
destroyed by boiling, their toxic products are not thus 
removed. 

The small flocculent curd of boiled milk is more 
easily digested than the large, tough, casein curds of 
raw milk. This is of distinct advantage in indigestion 
and diarrhea and in atrophy, as larger amounts of food 
and a more highly concentrated mixture can be admin¬ 
istered. Boiling, therefore, effectually disposes of the 
majority of bacteriologic problems, and is an excellent 
casein modifier. While some of the lactalbumin is 
coagulated, small amounts of the sugar are caramelized, 
and some cream and salts are lost in the scum the 
advantages of this method outweighs its shortcomings. 

In feeding boiled milk to infants, the danger of the 
development of rickets and scurvy can be positively 
obviated by the early addition of cod liver oil and 


FROZEN MILK 


87 


orange juice to the diet. A tendency to constipation 
develops, owing to the more complete digestion of the 
fine curds in the small intestine and the absence of the 
large, hard protein curd seen with raw milk feedings; 
but this can usually be counteracted by adding carbo¬ 
hydrates to the mixture. Duly considering all these 
facts, we believe that whenever there is any doubt as 
to the quality of the milk supply, the method of choice 
is boiling in the home, preferably by the double boiler. 
This should also apply to the reboiling of pasteurized 
milk whenever doubt exists as to its quality. 

FROZEN MILK 

Vomiting and not infrequently diarrhea follow the 
feeding of milk that has been frozen. So far as possi¬ 
ble, it is better to avoid the use of milk of this type. 
As this is not always possible, such milk should be 
boiled before being used in the feeding mixture. In 
most instances, the changes are in all probability 
physical, for in the freezing of the water the emulsion 
breaks and the fat becomes separated. When the milk 
is thawed, the fat globules coalesce and form a thick 
layer of butter fat which may cause a gastric and 
intestinal upset. Milk that has been frozen is less 
likely to show changes in the fat emulsion if the process 
of thawing goes on slowly in a cool room. 

Pennington 34 and her collaborators also found that 
changes occurred in the protein of milk that was held 
for a considerable period at a temperature of 0 C. 
These changes resulted in proteolysis of the casein and 
of the lactalbumin. 

34. Pennington, Hepburn, Witner, Stafford and Burrell: J. Biol. 
Chem. 16: 331, 1913. 



CHAPTER XIV 

CLINICAL ASPECTS OF INFANT FEEDING 

The general well-being of the infant is as important 
as the percentage and energy value of the food formula. 
In considering the two important factors in successful 
feeding, the chemical composition is as essential as the 
caloric value. Otherwise one encounters profound dis¬ 
turbances, difficult of interpretation, and due to feeding 
of either insufficient or excessive amounts of the com¬ 
ponents of the diet. 

The infant, therefore, must be fed amounts of fat, 
protein, carbohydrates, salts and water suitable to its 
constitution, age and physical development; these 
ingredients must be in proper proportion and sufficient 
in quantity to meet the caloric requirements of the 
young tissues for growth and development. The fact 
also must not be overlooked that the constituents of 
the diet must be in such form as will allow of normal 
digestion and assimilation. 

The wide range of tolerance of infants to their food 
has been mentioned, and that this, probably, largely 
accounts for the fact that so many pediatricians have 
successfully fed infants on mixtures which varied 
greatly both quantitatively and qualitatively. In all 
probability another factor is important in the explana¬ 
tion of these successes, namely, the fact that to a certain 
extent fats, carbohydrates and proteins are inter¬ 
changeable in the metabolic functions. 

The IVeight Curve .—In constructing a diet for 
infants, the individual needs must always be borne in 
mind. Allowance must therefore be made for basal 
metabolism, for growth, for muscular activity, and for 
the food values lost in the excreta (Holt). Indirect 
evidence as to the child’s progress is best obtained by 


THE WEIGHT CURVE 


89 


taking a careful history of its illnesses and feeding 
history. Direct evidence is best obtained by a careful 
study of the infant’s physical development and weight 
curve. One soon learns that a study of the infant’s 
weight is one of the simplest and most reliable clinical 
factors in estimating its progress. While infants vary 
considerably in their reaction to a given diet, according 
to their birth weight, subsequent care and previous diet, 
definite information of inestimable value is to be gained 
through the regular use of the scale. 

For practical purposes it is necessary that we know 
the average gain to be expected in normal artificially 
fed infants. It should be remembered that the breast¬ 
fed infant will average larger gains than the bottle-fed 
baby during the first six or eight months of life. For 
comparative purposes in the estimation of overweight 
and underweight in infants coming under observation, 
the following may be taken as working averages. For 
accuracy, a balance scale is necessary; the ordinary dial 
scale is unreliable. 

The average weight at birth is 7 pounds (3,200 gm., or 
about 3,333 gm.). 

The average initial loss is 10 ounces (300 gm.), or about 
one tenth of the body weight at birth. 

The birth weight is regained usually by the fourteenth 
day. 

The weight is doubled at the end of the fifth month, and 
trebled at the end of the first year. 

The average weekly gain during the first five months 
should approximate 5 ounces (150 gm.) ; during the remain¬ 
der of the first year, 4 ounces (120 gm.). 

The yearly gain during the second year is 6 pounds 
(2,727 gm.). 

The gain during the third year is 4 Vz pounds (2,000 gm.). 

The gain from the fourth to the eighth year is 4 pounds 
annually (1,800 gm.). 

The gain from the eighth to the eleventh year is 6 pounds 
annually (2,700 gm.). 


90 CLINICAL ASPECTS OF INFANT FEEDING 


It is not sufficient, however, to base the determina¬ 
tion of the amount of food on the weight of the baby 
alone, since two infants of the same weight may have 
decidedly different nutritional requirements. The fat 
baby requires less food per pound than the thin baby, 
and the overfed less than the underfed infant; the sick 
baby must of necessity be fed within its limits of toler¬ 
ance during the acute stage of its illness. The body 
losses must also be compensated for during con¬ 
valescence, as the baby’s tolerance for food permits, by 
increases in the diet beyond the normal feedings per 
pound of body weight. 

Within certain limitations, therefore, a healthy infant 
should show a regular gain. It is not absolutely neces¬ 
sary that an infant add to its body weight every day, as 
daily irregularities are the rule rather than the excep¬ 
tion. The relation of the time of weighing to feeding, 
defecation and urination must always be taken into 
consideration, and under normal conditions it is suffi¬ 
cient to weigh the infant once a week. It is especially 
wise to impress this on a nervous mother. 

Further, we must not forget that the weight curve of 
the nursing infant and that of the artificially fed infant 
differ widely, so that they cannot be directly compared. 
Although in the beginning the artificially fed infant 
gains less than the breast fed, in the course of a year 
he reaches the same weight. The latter at first shows 
larger gains, but later lags somewhat. Much more 
important than the weight itself is that the successive 
weight figures shall form a rising series. 

Caloric Needs .—Having determined the infant’s 
weight and obtained a fairly definite idea as to its 
general physical condition, its caloric needs should be 
estimated so as to gain an idea of its total dietetic needs. 
The estimation must of necessity be based on its 
existent weight curve, duly considering its general con- 


THE INFANT’S CALORIC REQUIREMENTS 91 


dition and its weight as compared with other infants 
of the same age. One should think not so much of pro¬ 
viding a given number of heat units as of the food 
elements necessary to furnish those units. Each gram 
of fat in the diet will furnish 9.3 calories, and each 
gram of protein and carbohydrates, 4.1 calories. 

Under this system the physician reckons the mini¬ 
mum daily caloric requirement, either from the present 
weight of the baby or what it should weigh in health, 
and then selects the food, so proportioning the fat, 
carbohydrate and protein content that it will not only 
meet the caloric requirements, but also will contain the 
proper amount in grams, of each of the constituents, to 
meet the infant’s needs for growth and development. 

In considering the caloric content, the part played 
by the various food components must be remembered. 
Benedict and Talbot 35 found that the basal require¬ 
ments are highest per kilogram at about the ninth 
month, and steadily fall from this time up to adult life. 
Holt and Fales 36 estimated that the food value nor¬ 
mally lost in the excreta is a nearly uniform proportion 
of the intake, about 10 per cent, for all ages after 
infancy, and that the requirements for growth are 
greatest during the first year of life, and during 
adolescence; also that the requirement for activity is 
the only factor which varies widely with different indi¬ 
viduals. As the emaciated infant is expected to gain 
more rapidly in proportion to its body weight than the 
fat and well nourished infant, it will of necessity 
require a food with a higher energy quotient to main¬ 
tain its growth ratio. 

The sick baby will rarely be able to digest an amount 
covering its full needs, as estimated by its body weight. 
Therefore, as in every other phase of infant feeding, 

35. Benedict, F. G.: Boston M. & S. J. 181: 107 (July 31) 1919. 

36. Holt, L. E., and Fales, H. L.: Food Requirements of Children: 
Totai Caloric Requirements, Am. J. Dis. Child. 21: 1 (Jan.) 1921. 



92 CLINICAL ASPECTS OF INFANT FEEDING 


individual consideration is necessary. It must be 
remembered that the nutrition of the baby depends on 
the quantity of food assimilated, and not on the quan¬ 
tity ingested. Less food is absorbed and utilized by 
the infant with deficient digestive power, and overfeed¬ 
ing will retard its progress. A comparative estimate of 
the infant’s diet, with a theoretical minimum, is of 
special value in cases in which doubt exists as to 
whether the retarded progress is due to insufficient food 
or to defective digestion and assimilation. 

Table 8.— Caloric Needs 


Average infants under 2 months of age, from 30 to 45 calories per 
pound (from 65 to 100 per kilogram) 

Average infants over 2 months of age, from 45 to 55 calories per 
. pound (from 100 to 120 per kilogram) 

Premature and thin infants under 2 months of age, from 50 to 65 
calories per pound (from 110 to 140 per kilogram) 

Thin infants older than 2 months, depending on their general condition, 
from 55 to 70 calories per pound (from 120 to 150 per kilogram) 


Repeated clinical experience proves that the earlier 
figures of Heubner and Rubner are too low for the 
average infant on bottle feedings. They estimated that 
the average healthy infant requires on the average 100 
calories per kilogram of body weight during the first 
six months of life, and from six months to the end of 
the first year approximately 85 calories per kilogram; 
and that 70 calories per kilogram of body weight is the 
energy quotient on which a baby can maintain a weight 
equilibrium. Instead of lessened caloric needs toward 
the end of the first years, his increasing activities 
demand heightening rather than lowering his food 
intake. Clinical observation in a large number of cases 
leads to the conclusion that, to assure satisfactory gain, 
the figures given in Table 8 must be approximated in the 
artificial feeding in infants. 

During the first few weeks of life of the artificially 
fed infant it is usually difficult to approximate these 
figures. 





CALORIES IN VARIOUS FOODS 


93 


Increases in the quantity of food should always be 
gradual, especially when malnutrition is present, and 
the infant must be carefully observed and increases 
made only as the food tolerance permits. 

Estimation of the caloric content of the food is not a 
feeding method, and should be used only as a check on 
overfeeding and underfeeding, the scale, stools, general 
condition, and particularly the disposition of the infant 
being the ultimate guide for dietetic changes. 

Table 9.— Caloric Values of One Ounce (Thirty Grams) 

of Various Foods 


Calories 


Cow’s milk. 21 

Human milk. 21 

Cream (16 per cent.). 54 

Skim milk. 11 

Buttermilk . 11 

Buttermilk mixture. 21 

Albumin milk. 12 

Chymogen milk. 21 

Keller’s malt soup. 25 

Cane sugar (by weight). 120 

Maltose-dextrin compounds (average). 110 

Malt-soup extract, dry, by weight. 90 

Malt-soup extract, dry, by volume. 132 

Corn syrup, by weight. 80 

Corn syrup, by volume. 110 

Flour, by weight. 100 

Cereal waters (1 ounce of cereal to the quart). 3 


The energy quotient is the number of calories which 
the infant is getting per pound or per kilogram of body 
weight. To determine the energy quotient of the diet, 
the number of ounces of each food ingredient of the 
food mixture is multiplied by their caloric values, the 
products are added, and the sum is divided by the num¬ 
ber of pounds or kilograms of the baby’s weight. 






















CHAPTER XV 


ESTIMATING THE AMOUNTS OF THE 
INDIVIDUAL FOOD ELEMENTS 

Protein. —Holt and Fales 37 found in their investiga¬ 
tions that the protein intake of the normal nursing 
infant is very low, ranging during the first nine months 
of life approximately from 8 to 12 gm. daily. This is 
equivalent to about 1.5 gm. per kilogram (0.7 gm. per 
pound). Up to the age of 8 or 9 months the protein 
taken by the nursing infant seldom exceeded 12 gm. 
daily. Our own observations indicate that most breast¬ 
fed infants will average a daily protein intake of 2 gm. 
per kilogram. 

When cow’s milk is substituted for human milk 
the protein intake is considerably increased—doubled 
or even at times trebled. Infants from 1 month 
to 9 months of age receive from 15 to 30 gm. 
of protein daily when fed on the usual modifica¬ 
tions of cow’s milk. This represents fully 3 gm. and 
often 4 gm. protein per kilogram (from 1.4 to 1.8 gm. 
per pound). The increase in protein requirement when 
cow’s milk is substituted for mother’s milk is probably 
due to the difference between the two milks in amino- 
acid content. Mother’s milk contains about twice as 
much lactalbumin (1.23 per cent.) as does cow’s milk 
(0.53 per cent.). The lactalbumin, which forms two 
thirds of the protein of mother’s milk, contains the 
highest proportions of the amino-acids leucin, lysin and 
tryptophan, of all the protein bodies. The work of 
Osborne and Mendel, 38 as well as that of others, has 
shown that lactalbumin is especially efficient in pro¬ 
moting growth, while casein, which forms one third of 

— — -——.——--———.—■ ■ - ■ - . - - i 

37. Holt, L. E., and Fales, H. L.: Food Requirements of Children: 
Protein Requirement, Am. J. Dis. Child. 22:371 (Oct.) 1921. 

38. Osborne, T. B., and Mendel, L. B.: J. Biol. Chem. 25: 1, 1916; 
ibid. 37: 223, 1919 



VEGETABLE PROTEINS 


95 


the protein of human milk (0.59 per cent.) and five 
sixths of the protein of cow’s milk (3.02 per cent.) is 
of comparatively low grade as a growth protein. The 
chief demands for protein are for compensation for 
wear and tear and to provide for growth. 

Holt and Fales found also that healthy children in 
their usual diet take about 4 gm. of protein per kilo¬ 
gram at the age of 1 year, the amount diminishing to 
about 2.5 gm. per kilogram at the age of 6 years. The 
young infant, as compared with the older child, requires 
proportionately a larger amount of protein to meet his 
needs for maintenance and growth. The total protein 
intake in the diet of infants and young children, per 
pound or kilogram of body weight, however, does not 
differ greatly in amount because the infant receives 
virtually all of his supply in the form of animal protein 
during his first year, the vegetable protein being repre¬ 
sented by the small amount received in cereals and 
vegetables. 

Vegetable proteins as a class are of distinctly lower 
grades than animal proteins. While they may be 
adequate for maintenance, it is hazardous with our 
present knowledge to depend on them for growth. 
Holt found that most of the children beyond the age 
of infancy took more than 60 per cent, of their total 
protein in the form of animal protein, from milk, eggs, 
meat, etc. The average was 66 per cent, of the total 
proteins from animal sources and 34 per cent, from 
vegetable sources. As vegetable protein cannot replace 
animal protein gram for gram, he believes that even if 
a larger proportion of vegetable protein than the usual 
one third of the total requirements is fed, the total pro¬ 
tein intake must be considerably increased. 

Sugars and starches, when added to a diet sufficient 
to meet any infant’s need, will, temporarily at least, 
cause a greater nitrogen retention. Fats have little or 


96 ESTIMATION OF AMOUNTS OF FOOD 


no influence. Nitrogen, to be retained, must be built 
up into living protoplasm, and to accomplish this salts 
must be available. Unless they are present, the 
nitrogen is again excreted. Approximately 1.7 gm. of 
ash are retained for each 1 gm. of nitrogen (Howland), 
or 0.3 gm. of ash for each 1 gm. of protein. 

The healthy, normal infant may be fed a minimum 
of iy 2 ounces of milk to a pound (100 c.c. per kilo¬ 
gram) of body weight, which would represent 1.5 gm. 
of protein per pound of body weight (3.5 gm. per 
kilogram). 

Notwithstanding what has been said on theoretical 
and experimental studies of the protein needs of the 
artificially fed infant, as compared with the amount of 
protein received by the breast-fed infant, it must be 
granted that the proteins of cow’s milk cover the pro¬ 
tein needs of the infant, and that when in excess they 
rarely cause nutritional disturbances if the tendency to 
large curd formation is prevented by boiling or alkalizing 
the milk. 

As a working minimum, the protein contained in 1% 
ounces of milk per pound (100 c.c. per kilogram) of 
body weight of the normal infant may be used, and in 
the underfed this quantity may be increased to an 
amount equal to 2 or 2 y 2 ounces per pound, thereby 
approximating H/i ounces per pound of what the baby 
should weigh for his age. Increases of milk in the 
diet must be gradual, the additions being governed by 
the child’s ability to handle the food. From what has 
been stated, it may be inferred that it is wise to estab¬ 
lish the protein content in a diet, which may then be 
supplemented by fats, carbohydrates and salts, because 
protein is the tissue builder and must necessarily be a 
basic constituent of all diets. 

Fats. —These are necessary to the normal growth 
and nutrition of the human body. But to a greater 


FATS 


97 


extent than the other food elements, they can for a 
time be replaced by proteins and sugars, more especially 
the latter. This explains why infants fed on low fat 
mixtures, more especially proprietary foods, such as 
condensed milk, will continue to gain in weight. How¬ 
ever, such development cannot be considered as normal, 
because the diet, besides being low in fat, rarely contains 
more than 1 per cent, of protein. 

Fats furnish part of the heat energy necessary to 
maintain the body temperature. They are stored as a 
reserve food. The fat is a protein saver, and when 
supplied in proper amount but little protein is used for 
the production of animal heat, thus allowing the protein 
to be retained in greater amount for building the body 
tissues. 

Fat is the carrier of the fat-soluble vitamins which 
are essential to normal growth, and in all probability 
have a direct relation to mineral metabolism. Fat also 
has a definite relation to calcium and probably mag¬ 
nesium metabolism independent of that due to its vita¬ 
min content. The best results in feeding are obtained 
when there is a definite relation between the fat and 
salt intake. Infants receiving an insufficient amount of 
fat in their diet show an increasing tendency to local 
and general infection, thereby giving evidence of 
lowered immunity. 

Some infants digest fats badly, and when a fat 
intolerance is once established it is overcome only with 
great difficulty. In such cases it is necessary to throw 
on the carbohydrate the burden of furnishing the neces¬ 
sary extra food. Such a catastrophe should be avoided, 
as infants receiving an insufficient amount of fat rarely 
thrive satisfactorily. We should therefore aim to stay 
within safe limits. When the diet contains an insuffi¬ 
cient quantity of fat, a high percentage carbohydrate 
feeding is usually instituted. This prevents the forma- 


98 ESTIMATION OF AMOUNTS OF FOOD 


tion of soap stools, and tends to the development of diar¬ 
rhea. For the formation of soap stools it is necessary 
that there be no excess of carbohydrate, and that there 
be present in the diet a relative excess of protein or 
fats or both. The resulting change in the chemical 
content of the bowel also has a decided influence on 
the bacterial flora in that the fat excreted in the 
intestinal tract combines with alkalis, which tend to 
overcome an excessively acid intestinal content. 

Holt, in his studies, found that the nursing infant 
usually receives, during its first weeks, as much as 
20 gm. of fat daily, and that the total increases by the 
seventh month up to an average of 40 gm. daily, the 
latter representing about 4 gm. per kilogram (1.8 gm. 
per pound) of body weight. Each gram of fat has an 
energy value of 9.3 calories, while protein and carbo¬ 
hydrate each furnishes 4.1 calories per gram; therefore, 
each gram of fat provides for more than twice as many 
calories. The tendency toward normal growth and 
development on the part of a nursing infant on a high 
fat feeding illustrates the value of this element in the 
diet. 

Our clinical experience has demonstrated that while 
the tolerance for the fat of cow’s milk varies greatly in 
different individuals, most infants will digest and assim¬ 
ilate 1.8 of fat per pound of body weight daily. This 
is the quantity contained in 1% ounces of average 
cow’s milk of good quality (4 gm. per kilogram, the 
amount contained in 100 c.c.). This quantity will also 
supply the body needs for growth and development 
when associated with sufficient protein and carbo¬ 
hydrate. 

Carbohydrates .—These are used chiefly to supply 
heat and energy, to supply in part material for fat 
foundation, thereby partly replacing the fat waste. 
Because of their high caloric value, they supply a large 


CARBOHYDRATES 


99 


amount of energy. They are efficient sparers of pro¬ 
tein, and will supply energy in case of fat insufficiency 
in the diet. Synthetically, they are converted into 
glycogen in the body. Fat is formed from sugar by the 
subcutaneous cells, which are especially adapted to this 
function. 

Normally, in greater part, sugar is absorbed from 
the small intestine and is not found in the feces. If 
absorbed in sufficient quantity it will cause a rapid 
increase in weight. When insufficient carbohydrate is 
supplied to the body, it supplies the deficiency by 
breaking down the body protein. 

The majority of infants have a high carbohydrate 
tolerance, and the same is true of most infants suffer¬ 
ing from nutritional disturbances. Exceptions to this 
are seen in some of the fermentative diarrheas, some 
eczemas, and exceptionally in a few other conditions. 
Fortunately, the ability to metabolize carbohydrates is 
often present even though fats and proteins are poorly 
digested. 

For practical purposes, the carbohydrates used in 
infant feeding may be divided into three large groups: 

(1) the disaccharids, of which saccharose (canesugar), 
lactose (milk sugar) and maltose are the best examples; 

(2) the polysaccharids, of which the cereals, flours and 
dextrin are most commonly used, and (3) mixtures of 
the disaccharids and polysaccharids, combinations of 
which are contained in most of the proprietary infant 
foods. 

Cane and Milk Sugars .—As regards the relative 
nutritive value of cane sugar and milk sugar, there is 
little to recommend one over the other so far as their 
food value and the limit of tolerance are concerned. 
When large quantities of lactose are fed, a laxative 
effect is more frequently seen than with cane sugar 
feeding of simillar quantities by weight. Cane sugar 


100 ESTIMATION OF AMOUNTS OF FOOD 


is heavier than lactose; two tablespoonfuls of the 
former and three of the latter approximate 1 ounce by 
weight. Cane sugar will answer the needs of most 
infants. This assertion is based on a large experience 
with infant-welfare patients among whom economy, of 
necessity, had to be considered. 

The total carbohydrates (sugar contained in the milk, 
sugar added to the milk, and cereal, if used), should 
average from one-eighth to one-fifth ounce (4 to 6 gm.) 
per pound (from 9 to 13 per kilogram) of body weight a 
day. One and one-half ounces of milk, averaging 4.5 
per cent, carbohydrate, furnishes 2 gm. of lactose. 
Normal full-weight infants will usually require a mini¬ 
mum addition of one-tenth ounce (3 gm.) by weight of 
sugar to the milk mixtures for each pound of body 
weight (6.6 gm. per kilogram). For underweight infants 
the amount should at first be calculated on the basis of 
their present weight, but increased if zvell taken, to meet 
the amounts indicated for a full-weight infant of 
similar age. 

Carbohydrates needed beyond that furnished by IV 2 
ounces of sugar should be supplied by well cooked 
cereals or cereal waters, because of the danger of fer¬ 
mentative diarrhea. (See mixed feeding.) 

Holt and Fales, 39 in their investigations on nursing 
infants, found that they took, on the average, about 
12 gm. of carbohydrate per kilogram of body weight 
daily. Artificially fed infants usually received some¬ 
what more than this. They believe that an infant of 
average activity should at one year be allowed about 
12 gm. of carbohydrate per kilogram of body weight, 
the amount being decreased to about 10 gm. per kilo¬ 
gram at 6 years, and maintained at this value through¬ 
out the remainder of the growth period. 

39. Holt, L. E., and Fales, H. L.: The Food Requirements of Chil¬ 
dren: Carbohydrate Requirement, Am. J. Dis. Child. 24: 44 (July) 1922. 



CANE AND MILK SUGARS 


101 


The sugar content of the food of infants who have 
been on a low sugar diet should be gradually increased 
in order that they may become accustomed to the 
altered amounts. 

In changing from one kind of sugar to another, it is 
always safe to reduce the quantity for a few days, 
further increases being governed by the infant’s toler¬ 
ance. Partially replacing of the disaccharids by cereal 
waters and gruels usually results in the amelioration of 
digestive disturbances following the use of excessive 
amounts of sugars. Clinical observations have led to 
the belief that both sugar and well cooked starches, 
after the second month, have distinct advantages in the 
diet. 

Maltose and Dextrin Compounds. —These have little 
to recommend them in the feeding of most infants. 
They can usually be administered in somewhat larger 
quantities: one-eighth ounce (4 gm.) for every pound 
of normal weight. However, it is to be remembered 
that similar amounts of carbohydrates can be given by 
- feeding cereals with sugars. In using maltose and 
dextrin compounds it is to be remembered that their 
action on the bowels varies greatly, depending on their 
maltose, dextrin and alkali content. Thus, we find that 
proprietary foods containing a considerable percentage 
of dextrin, in the absence of added potassium salts, are 
constipating, while those with a high maltose content, 
more especially when containing potassium carbonate 
or bicarbonate, are laxative in their effect. 

Cereals.—Cereals in water or gruels may be added 
to the milk mixtures in quantities varying from one- 
sixtieth to one-thirtieth ounce (0.5 to 1.0 gm.) for each 
pound of body weight, daily (1.0 to 2.0 gm. per 
kilogram). Cereal waters may be used as a diluent 
as early as the second month of life, and the 
cereal gruels by the fourth month. The addition 


102 ESTIMATION OF AMOUNTS OF FOOD 


of a second carbohydrate to the infant’s diet is 
frequently followed by increases in the weight curve 
out of proportion to the food value of the cereals. This 
is especially true when the whole grain rather than the 
dextrinized flours is used in the preparation. It cannot 
be stated whether this is due to vitamins or vegetable 
proteins contained in the preparations made from the 
whole grain. The cereals also have a decided influence 
on the calcium and magnesium balance, owing, in all 
probability, to the same factors. 

Salts .—Human milk contains 0.2 gm. of ash in 100 
c.c., and cow’s milk 0.75 gm. of ash in 100 c.c. The 
difference in percentage in human and cow’s milk is 


Table 10 .—Grams of Salts in 1,000 c.c. of Milk 



CaO 

MgO 

P 2 0 5 

Na 2 0 

K 2 0 

Cl 

Fe 

Human milk... 

0.458 

0.074 

0.345 

0.132 

0.609 

0.358 

0.0017 

Cow’s milk.. . . 

1.72 

0.2 

2.437 

0.465 

1.885 

0.822 

0.0007 


equalized by the body’s using only what is necessary 
for its life and growth. The salts are absolutely neces¬ 
sary for the life of the organism. 

Holt, Fales and Courtney, in their studies on calcium 
metabolism, concluded that: 

The total absorption of calcium oxid varied in general 
with the weight of the child. . . . An excessive calcium 

intake apparently did not increase the calcium absorption, 
the excess being excreted. 

The average absorption of calcium oxid by healthy infants 
taking modifications of cow’s milk was 0.09 gm. per kilo¬ 
gram of body weight. Since the average absorption of cal¬ 
cium oxid by breast-fed infants was 0.06 gm. per kilogram, 
it may be assumed that 0.06 gm. per kilogram is the minimum 
normal absorption by infants taking modifications of cow’s 
milk. 

To insure the average absorption of 0.09 gm. of calcium 
oxid per kilogram, the intake of calcium oxid should be at 
least 0.19 gm. per kilogram with cow’s milk feeding; to 





SALTS 


103 


insure an absorption equal to the average found for breast¬ 
fed infants, the intake of calcium oxid should be at least 
0.13 gm. per kilogram. 

The best absorption of calcium was obtained when the 
calcium intake bore a definite relation to the fat intake, that 
is, when the food contained from 0.045 to 0.060 gm. of cal-* 
cium oxid for every gram of fat, and when at the same time 
the fat intake was ample, not less than 4 gm. per kilogram. 

An infant receiving one tenth of its body zveight in 
milk, that is, 100 gm. per kilogram (one and one-half 
ounces per pound) of body zveight zvill have an intake 
of 0.17 gm. of calcium oxid per kilogram (0.08 gm. per 
pound). At the same time, the infant zvill have an 
intake of 4 gm. of fat per kilogram (1.8 gm. per 
pound). 

The percentage content of magnesium, sodium and 
potassium salts is approximately the same in human 
and in cow’s milk; but quantitatively, in cow’s milk, it 
is about three times as great. Therefore, in mixtures 
containing the recommended amount of cow’s milk 
there will be about 50 per cent, more of these salts than 
in the average quantity of breast milk taken by an 
infant. 

Of the inorganic constituents, phosphorus ranks 
among the most important. Human milk contains 
0.345 and cow’s milk 2.437 gm. of phosphorus pentoxid 
per liter, a ratio of about 1 to 8. Of this, approxi¬ 
mately 43 per cent, in human milk and 46 per cent, in 
cow’s milk exists as organic compounds. Various 
authors find that from 53 to 80 per cent, of the phos¬ 
phorus in cow’s milk, and from 65 to 90 per cent, in 
human milk, is absorbed. If these figures are correct, 
we may be assured that there is at least sufficient phos¬ 
phorus in cow’s milk mixtures to provide for the 
infant’s needs. Therefore, a question of more impor¬ 
tance is the ability of the infant to fix in its body tissues 
the phosphorus which it receives in its diet. 


104 ESTIMATION OF AMOUNTS OF FOOD 


Theoretically, at least, the iron content in breast as 
well as cow’s milk is insufficient to meet the infant’s 
requirements, and in both instances it must draw to 
some extent at least on its iron deposits. In artificial 
feeding it is especially important during the first six 
months that provision be made for supplementing from 
other sources the iron contained in the cow’s milk. 

Salts are necessary for building the body tissue, and 
each gram of protein retained and built into the body 
tissue requires approximately one-third gram of ash. 

The average infant receiving cow’s milk, with its 
greater salt content, lives on a higher plane of mineral 
metabolism than one receiving breast milk. In the 
majority of infants, this excessive salt intake undoubt¬ 
edly does no harm; the surplus is not absorbed, and is 
merely eliminated. 

Sodium and potassium are usually well retained, 
unless severe diarrhea is present or there is an excess 
of fat or of sugar in the diet. Under such circum¬ 
stances the salts are lost, and the loss is badly borne 
and cannot indefinitely be continued. When all avail¬ 
able alkalis have been drawn on, the infant breaks down 
its own tissue to furnish more of these substances, 
which explains, in part at least, the excessive nitrogen 
excretion in such cases. When diarrhea ceases and the 
intake is sufficient, a positive balance is rapidly 
instituted. 


CHAPTER XVI 


SUMMARY OF QUANTITATIVE AND CALORIC 
RELATIONSHIP OF THE FOOD 
CONSTITUENTS 

In the diet recommended as a minimum for the aver¬ 
age normal infant on a diet of cow’s milk with added 
carbohydrates, namely; per pound, milk V/2 ounces, 
sugar 1/10 ounce and starch 1/60 ounce, or per kilo¬ 
gram, milk 100 c.c., sugar 6.6 gm. and starch 1.1 gm., 
the distribution of ingredients would be as in Table 11. 

Table 11. — Ingredients in Minimal Diet 


Proportion of Amounts—^ ,—Distribution of Calories- 



Per 

Per Kilo- 

Per 

Per 

Ter Kilo- 

Per 


Pound 

gram 

Cent. 

Pound 

gram 

Cent. 


Grams 

Grams 




Fat ... . 

. 1.8 

4.0 

20.5 

16.74 

37.2 

37 

Protein 

. 1.5 

3.5 

17 

6.15 

14.35 

14 

Sugar. . 

Starch . 
Calcium 

( in milk 2.0 
{ added 3.0 

. 0.5 

oxid.... 0.08 

4.5 1 

6.6 } 
1.1 j 

0.176 

62.5 

22.55 

49.61 

49 

Total. .. 

, . 45.44 

101.16 






The ratio of the amounts of the components of the 
diet, when expressed in percentages, shows: fat, 20.5; 
protein, 17; carbohydrate, 62.5; that of the caloric dis¬ 
tribution of the ingredients is: fat, 37; protein, 13.5; 
carbohydrate, 49.5. 

The amount of fat in the diet, therefore, slightly 
exceeds the protein, while the carbohydrate is some¬ 
what more than three times the fat or protein. 

The caloric value of the diet, however, shows that the 
fats are about two and one-half times the protein, while 
the combined fat and protein calories about equal the 
carbohydrates. 

Holt, 40 in studying the diets of a series of 106 chil¬ 
dren, ranging in ages from 1 to 18 years, found that 

40. Holt, L. E.: Food, Health and Growth, New York, the MacMillan 
Company, 1922. 













106 SUMMARY OF FOOD CONSTITUENTS 


the average percentage distribution of the food intake 
in calories was: fat, 35; protein, 15; carbohydrate, 50. 

The combined calories of food elements usually 
recommended for the normal infant average 45 for each 
pound, or 100 calories for each kilogram body weight. 
Clinical experience leads me to recommend this amount 
as the minimum required by the average artificially 
fed infant of the second month (see caloric needs). 
The greater needs of the individual infant for growth 
are to be met by increasing the total food given or 
such of the ingredients as may be indicated. Only 
under exceptional circumstances should the suggested 

Table 12. — Calories in Fat, Protein and Carbohydrates 


Fat .1 gram = 9.3 calories 

Protein .1 gram = 4.1 calories 

Carbohydrate .1 gram = 4.1 calories 


proportions be deviated from to any considerable 
amount, and then only through the reparation stage if 
normal development is to be expected. 

NUMBER OF FEEDINGS IN TWENTY-FOUR HOURS 

Four-Hour Intervals .—It has been proved that the 
usual cow’s milk mixtures fed to infants do not leave 
the stomach completely for at least three hours after 
ingestion. Most normal infants will be satisfied when 
placed on suitable mixtures at four-hour intervals. For 
several years, normal infants have been fed successfully 
on four-hour periods. The most suitable hours are 
6 and 10 a. m., and 2, 6 and 10 p. m., with a 2 a. m. 
feeding if necessary. Most infants will be satisfied 
with five feedings daily from birth. 

Three-Hour Intervals .—If the three-hour interval is 
indicated, one should begin with seven feedings in 
twenty-four hours for the first month (6, 9, 12, 3, 6, 
10, 2) ; six feedings during the second and third months 








FLUIDS REQUIRED 


107 


(6, 9, 12, 3, 6, 10), and five feedings by the fourth to 
the fifth month (6, 10, 2, 6, 10), according to the indi¬ 
vidual need. 

Premature and delicate infants having a tendency to 
vomit, as such cases are exceptions, may be fed smaller 
amounts more frequently, even at two-hour intervals, 
if indicated. In case catheter feeding is necessary, the 
longer interval will usually suffice. 

Water to Be Added .—It is most important to remem¬ 
ber that young infants require a minimum of one fifth 
of their body weight of fluids daily (3 ounces per 
pound), and in their later months at least one sixth of 
their body weight (2% ounces per pound) daily. 

For the average normal infant, the amount of water 
to be added to the mixture is calculated by estimating 
that young infants, after their first few weeks of life, 
should be given 3 ounces of fluid daily per pound (200 
c.c. per kilogram) of body weight, and older infants 
2i/ 2 ounces. The difiference between the total fluids 
required by the infant for a day’s feeding, and the 
amount of milk fed, equals the amount of water to 
be added. The food mixture is divided into equal 
portions, the number of which will vary with the 
feeding interval. Infants having a tendency to vomit 
usually have to be limited to 2% ounces of fluid per 
pound of body weight. 

Underweight infants will require a total of fluids 
approximately 3 ounces, or at times even more per 
pound of body weight. Very fat infants will often be 
satisfied with somewhat less water than suggested. 

After the fourth month, the average infant will take 
at least one quart of the food mixture daily. By this 
time a mixed diet may be instituted by adding a well 
cooked cereal to one or two of the day’s feedings. 

After the sixth month, four meals of 8 ounces each 
of a milk mixture may be given, and a fifth meal of a 


108 SUMMARY OF FOOD CONSTITUENTS 


vegetable broth may be added. Mixed feeding will be 
discussed more fully under Additional Foods. 

It has been found that a concentrated milk mixture 
does not disturb the infant’s digestion when the milk is 
boiled, when cereal waters are used as diluents, or when 
it is alkalized by the addition of sodium citrate or lime 
water. 

Carbohydrates to Be Added. —Having the necessary 
amount of milk and water, we ascertain the amount 
of carbohydrates to be added. Cane or milk sugar 
will satisfy the needs of the average normal infant 
during its first month when added in amounts of 
one-tenth ounce (3 gm.) per pound. Somewhat more 
than twice this quantity (6.6 gm.) should be added 
per kilogram of body weight to the day’s mixture. 
Cane sugar mixtures are occasionally refused by 
infants when large amounts are added because they 
are too sweet. In such cases, part of the sugar 
can be replaced by milk sugar or maltose-dextrin 
compounds. 

After the infant is 1 or 2 months old, from one- 
sixtieth to one-thirtieth ounce (0.5 to 1 gm.) of cereal 
or cereal flour for each pound of body weight may 
be added to the mixture. This is best given as cereal 
water. The addition of the second carbohydrate often 
has a very beneficial effect on the weight curve. 

In underweight infants, the amount of sugar to 
begin with should be calculated on the basis of the 
existent weight, approximating the quantity needed for 
a full-weight infant as rapidly as the sugar tolerance 
permits. 

Table 13 gives equivalents of 1 ounce by weight and 
the domestic' measures of carbohydrates used in the 
artificial feeding of infants. 

To Break the Curd to Assist Digestion of Cow’s 
Milk. —Many infants can digest raw cow’s milk. 


THE CURD IN COW’S MILK 


109 


When it is not well digested, the formation of large 
protein curds is obviated by boiling the milk from 
two to three minutes over the flame or, better, by 
putting it in a double boiler and heating it until the 
water in the outer vessel boils eight minutes. Although 
the curd is less finely divided by the use of the double 
boiler as compared with boiling over the direct flame, 
it answers the purpose for most infants and causes 
fewer changes in the milk. A small double boiler 
should be used, as in it the column of milk is deep 
and has a small surface. The milk should simmer 

Table 13.— Equivalents of an Ounce 


By 

Weight 



Ounce 

Grn 

Cane sugar. 

. 1 

30 

Milk sugar. 

. 1 

30 

Maltose-dextrin . . . 

. 1 

30 

Flour (wheat).... 

. 1 

30 

Flour (barley) .... 

. 1 

30 

Barley (pearl) .... 

. 1 

30 

Oats (rolled). 

. 1 

30 


By 

Measure 

Spoonfuls, Leveled 
with Knife 

Ounces 

Table 

Dessert 

Tea 

1.00 

2 

3 

6 

1.50 

3 

4.5 

9 

1.50 

3 

4.5 

9 

2.25 

5 

7.5 

15 

1.50 

3 

4.5 

9 

2.50 

5 

8 

15 

2.50 

5 

8 

15 


1 tablespoonful = 1.5 dessertspoonfuls = 3 teaspoonfuls 


rather than boil actively, and in the larger vessel boiling 
takes place more readily. Milk that has been simmered 
undergoes less change in taste than that which has 
been actively boiled and there is less loss of soluble 
protein, fat, sugar and salts. 

The feeding of raw diluted cow’s milk has certain 
unquestionable advantages; however, when its source 
is in any way doubtful or its subsequent handling is 
likely to have led to contamination, it should be either 
pasteurized or boiled. 

Cereal water diluents cause the formation of fragile 
curds. Addition of sodium citrate to the milk mixtures 
also prevents the formation of hard protein curds. 
Sodium citrate may be prescribed either in 5-grain 
tablets, .approximately one-half to 1 grain being added 













110 SUMMARY OF FOOD CONSTITUENTS 


for each ounce of the milk mixture, or a prescription 
may be so written that each teaspoonful of the pre¬ 
scribed formula will contain sufficient sodium citrate 
for the day’s food. 

When lime water is added to cow’s milk until it is 
neutral or faintly alkaline to phenolphthalein, a basic 
calcium casein is formed which is not acted on by rennet 
and will not form a curd, even in the presence of lime 
salts (Van Slyke). Lime water is commonly used in 
amounts equaling 5 per cent, of the milk in the mixture 
(1 ounce to 20 ounces of milk). In most instances no 
advantage is gained by adding alkalis to boiled milk 
mixtures. Occasionally the addition of sodium citrate 
or lime water to boiled milk will be found of advantage 
in cases of difficult feeding and in the presence of 
vomiting. 



Fig. 8.—Utensils needed for artificial feeding: fine sieve; doable boiler (small); bottle brush; feeding bottle; bottle rack; paper 
caps; nipples; nipple jar; funnel; glass graduate; milk, 1 quart; water (boiled); cereal; sugar; tablespoon; dairy thermometer. 

















CHAPTER XVII 


PRINCIPLES GOVERNING THE PREPARATION 
OF MILK MIXTURES 

So far as it has been developed by the scientific 
knowledge of the present day, the basis to be recom¬ 
mended for the artificial feeding of average normal 
infants is the unit requirements in fat, protein, carbo¬ 
hydrate, salts, water and accessory food factors per 
pound or kilogram of body weight. 

It is therefore evident that there must be a rational 
understanding of the infant’s digestive and metabolic 
processes as concerns the individual ingredients of his 
diet, and that the quantitative relationship of the indi¬ 
vidual components of the diet to these physiologic 
processes must be duly considered. It soon becomes 
evident that while in many instances one or more of 
the food elements may cause digestive disturbance, 
poorly balanced combinations of these elements have 
a far greater influence on its development. If all the 
ingredients are in excess, it may cause a general upset 
to develop rapidly; but the insufficiency of one or more 
of the ingredients usually results in the more chronic 
type of nutritional disturbances. One of the best 
illustrations of the latter type is seen when proper 
quantities of fat and protein are fed but the carbohy¬ 
drates are insufficient. A similar but less constant 
picture presents itself when fat is insufficient in an 
otherwise well balanced diet. 

It is therefore necessary to consider, first, the 
fundamental principles governing nutrition, basing 
these on knowledge not only of the digestion, absorp¬ 
tion and later metabolism of the individual food 
elements, but also of their relative action. It must 
also be remembered that an improperly constituted 


112 PREPARATION OF MILK MIXTURES 


diet reacts on both the quantity and quality of the 
digestive secretions, affords pathogenic bacterial flora 
a suitable medium in which to develop, and accelerates 
or delays the intestinal reaction, having thus a direct 
effect on the infant’s development. 

While the chemical composition of the diet must be 
most carefully considered, its quality, as regards its 
freshness and purity, is equally important. Therefore, 
in providing a suitable food, its source, subsequent 
handling and finally its proper modification must be 
supervised. A study of the literature arising during 
the last half century, concerning the many theories and 
methods advanced for the feeding of infants, empha¬ 
sizes that no substitute has been found for hitman milk. 

When an infant is fed on food not primarily intended 
for its use, attempts at adaptation must be made, and 
their number as mentioned in the literature shows con¬ 
clusively that no single method can possibly meet all 
demands. 

Realizing that rigid dogmatism will ultimately lead 
to confusion, it is our object here to formulate prin¬ 
ciples of feeding which are adaptable to the majority 
of well babies and will allow for their physiologic 
development. The discussion of the feeding of sick 
infants will be considered later. Such principles, to 
be worthy of recommendation, must permit of elas¬ 
ticity in the administration of individual ingredients 
and must be based on our present knowledge of the 
needs of the body for growth and development. It is 
to be remembered that the diets to be recommended, 
although meeting the requirements of most infants, 
will be excessive for some and inadequate for others. 
Infants differ in their use of the food administered. 

In formulating a scientific basis for infant feeding, 
we must recognize that at present no hard and fast 


INTERPRETATION OF REQUIREMENTS 113 


rules can be laid down for clinical application. Our 
present methods are still more or less empiric, and 
the result is dependent to a considerable degree on the 
wide range of food tolerance of the healthy infant. 
Hence in order to insure success the physician must 
depend on his own clinical observations. 

The needs of the normal breast-fed infant are well 
known. The breast-fed infant taking 2% ounces of 
milk per pound of body weight receives fat, 2.6, pro¬ 
tein, 1.1, and carbohydrate, 5 gm., daily for each 
pound of weight. So long as he receives daily 2% 
ounces of breast milk per pound of his body weight, 
it matters little to him whether he is given frequent 
feedings of small amounts or the more desirable larger 
individual feedings at longer intervals. 

It should be emphasized that the needs of the arti¬ 
ficially fed infant for the various food elements must 
be interpreted on the same basis of unit requirements 
per pound or kilogram of body weight. If the adop¬ 
tion of this method were to secure no other result 
than to cause a collection of facts from the various 
clinics for comparative study, it will have served a 
good purpose. 

In the past, percentages of the food elements in their 
relation to the total milk mixture have been used, 
orders being written for two-thirds milk mixture, plus 
5 per cent, carbohydrate, or a mixture containing fat, 
2 per cent., protein, 1 per cent., and carbohydrates, 6 
per cent., etc. This, more than any other method, has 
led to the many so-called schools of infant feeding 
and possible misinterpretation of end-results. In our 
present consideration of the infant’s food require¬ 
ments, his needs in fat, protein, carbohydrates, salts 
and water will be discussed with regard to each pound 
or kilogram of body weight, secondary emphasis being 


114 PREPARATION OF MILK MIXTURES 


given to the percentages in the mixture. The German 
schools of pediatrics were the first to emphasize the 
caloric requirements of the infant and to make use 
of these as a basis for calculating food supply. This 
led in many instances to unbalanced diets, because heat 
units were thought of rather than food elements. The 
caloric content of the diet will be considered, therefore, 
chiefly as constituting a check on overfeeding and 
underfeeding as a whole and not as a basis for 
constructing diets. 

The question presenting itself to the practitioner is 
this: Can this principle he practically applied in every¬ 
day infant feeding? 

Every formula with which feeding is begun should 
he looked on as experimental, and the reaction of the 
infant to this feeding should he carefully studied. 

If these principles are borne in mind, many an 
obstacle to successful infant feeding will be overcome. 

The attempts toward ultrarefinement of the infant’s 
diet have led to considerable confusion because of the 
different conclusions of the various schools. Eventually 
infant feeding will be placed on a thoroughly scientific 
basis. This, however, does not answer the present-day 
needs, which call for a safe and practical solution of 
the feeding problem for the every-day baby in every¬ 
day life. Feeding advice commonly comes from food 
manufacturers, and if one preparation is not successful 
a rapid transition is made from one proprietary baby 
food to another, with untold detriment to the infant. 
In clinical experience, the rules advocated for feeding 
the normal healthy infant on simple milk mixtures 
with carbohydrates added, with further suggestions for 
the underfed, have been found safe for the baby and 
practical for the physician, which latter is to be neither 
overlooked nor taken lightly. 


DATA FOR ESTIMATING DIET 


115 


DATA AS TO FOOD AND FOOD REQUIREMENTS 
USED AS A BASIS FOR ESTIMATING 
THE DIET OF INFANTS 

Average cow’s milk contains the percentages given 
in Table 14. 

The grams of food elements needed as a minimum 
in twenty-four hours by the average normal artificially 
fed infant are given in Table 15. The milk or cream 

Table 14. — Content of Cow's Milk 


Per Cent. 


Fat . 4.0 

Protein . 3.5 

Carbohydrates . 4.5 

Calcium oxid. 0.172 


Table 15. —Grams of Food Elements Needed as a Minimum 
in Twenty-Four Hours by the Average Normal 
Artificially Fed Infant 



Per Pound 

Per Kilogram 

Fat. 

. 1.8 

4.0 

Protein . 

. 1.5 

3.5 

Carbohydrates. 

. 5.0 

11.0 

Calcium oxid. 

. 0.08 

0.17 

Water. 

. 90.0 

200.0 


Table 16. —Ingredients to Be Added for Each Gram of 

Food Elements 


Fat . Vio oz., or 6 c.c., of cream 

% oz., or 25 c.c., of milk 

Protein .1 oz., or 30 c.c., of milk or skim milk 

Carbohydrates.!k) oz., or 1 gm., of sugar 

Calcium oxid.18.5 oz., or 600 c.c., of milk or skim milk 


and skim milk needed to supply fat and protein will 
average 2 gm. of sugar. It will therefore be necessary 
to add the amount needed in excess of this, one-tenth 
ounce (3 gm.) per pound, or 6.6 gm. per kilogram. 

For each gram of food elements in the mixture, the 
ingredients listed in Table 16 must be added. 

























116 PREPARATION OF MILK MIXTURES 
Table 17. — Requirements for Each Pound of Body Weight 


Fat (1.8 gm.).1)4 oz., or 45 c.c., of milk 

Protein (1.5 gm.)......1)4 oz., or 45 c.c., of milk or skim milk 


Carbohydrates (3.09 gm.)... .Mo oz., or 3 gm., of sugar 

Calcium oxid (0.08 gm.)....l)4 oz., or 45 c.c., of milk or skim milk 


Table 18. —Requirements for Each Kilogram of Body Weight * 


Fat (4.0 gm.). 25 c.c. of cream; 100 c.c. of milk 

Protein (3.5 gm.).100 c.c. (of milk or skim milk) 

Carbohydrates (6.6 gm.).6.6 gm. of sugar 

Calcium oxid (0.172). 100 c.c. 


* No allowance made for protein in cream. Protein figured at 3.5 per 
cent, in milk. 


WHOLE MILK DILUTIONS WITH CARBOHYDRATE 

ADDITIONS 

In applying the rules for the feeding of normal, 
healthy infants it must be remembered, as previously 
emphasized, that each infant must be fed to meet its 
individual requirements. Therefore the rules must be 
so modified as to meet the individual demands. If 
milk dilutions with the addition of carbohydrates are 
used, the simplest and most natural standard is that 
which tells us how much milk and carbohydrates the 
baby should get per pound or per kilogram of body 
weight. 

To he exact, we should express, or at least he azvare 
of, the number of grants of proteins, fat, carbohydrates, 
salts and water that the infant is receiving for each 
pound of its body weight. 

If statistics on infant feeding were collected on this 
basis rather than on percentages of the ingredients in 
the milk mixtures (the total mixtures used by different 
physicians being of such variable quantity), the col¬ 
lected data zvould be far more valuable as a basis for 
future work in infant feeding. 

In every instance the general health of the infant is 
of the greatest importance in estimating its capacity 
for assimilating the diet. 
















CARBOHYDRATE ADDITIONS 


117 


To meet the minimal per pound body weight protein 
(1.5 gin.), fat (1.8 gm.), and calcium oxid (0.08 gm.) 
requirements, the average normal infant will require 
each day a minimum of iy 2 ounces (45 c.c.) of cow's 
milk. For each kilogram of body weight, 3.5 gm. of 
protein and 4.0 gm. of fat will be required. These will 
be furnished by 100 c.c. of cow's milk. 

For normal full weight infants, the addition of one- 
tenth ounce (3 gm.) by weight of sugar to the milk 
mixtures will be required for each pound of body 
zveight ( 6.6 gm. per kilogram). 

Water equal to 3 ounces per pound, or one-fifth the 
body weight, will meet the day's requirements for 
young infants, and amounts approximating 2% ounces 
per pound, or one-sixth the body weight, will answer 
for older infants. The difiference between the total 
day’s fluid requirement and the milk in the mixture 
can be added as boiled water or cereal water or a 
portion of it may be fed between meals. 

Cereals in the form of thin gruels may be added to 
the milk mixtures in quantities varying from one- 
sixtieth to one-thirtieth ounce (0.5 to 1 gm.) for each 
pound of the body weight after the first or second 
month of life. 

A mixture formulated to include these recommended 
amounts of food ingredients will average about 45 
calories for each pound of body weight (Table 19). 

Practical clinical experience has taught us that 
infants fed on cow’s milk mixtures will frequently 
require approximately 2 ounces (60 c.c.) of cow’s milk 
per pound of body weight, except during the first few 
weeks of life, when smaller quantities of whole or 
skim milk are indicated. Such mixtures will average 
approximately 55 calories for each pound of body 
weight. 


118 PREPARATION OF MILK MIXTURES 


In beginning feeding with cow’s milk, mixtures 
must always be started as weak formulas, more often 
only 1 ounce (30 c.c.) of cow’s milk being used to a 
pound of body weight, the strength being gradually 
increased to meet the infant’s needs. 

Underweight infants should be fed according to their 
weight at the initiation of feeding, the strength of the 
mixture being increased gradually but rapidly as the 
baby shows ability to handle the food, thus approxi¬ 
mating the needs of a full-weight baby of the same age, 
in milk, sugar and water. These babies will fre¬ 
quently, therefore, require 2 ounces (60. c.c.) or more 
of milk per pound of body weight, and carbohydrates 
must be added in proportion. 

Table 19. —Mixture Containing Recommended Amounts of 

Food Ingredients 


Milk, 1J4 ounces = 30 calories 
Sugar, Vio ounce = 12 calories 
Starch, i£o ounce = 3 calories 

45 


With the institution of a mixed diet, the infant thrives 
with less milk per pound of body weight. 

In preparing to feed an infant these general rules 
should be followed: 

The baby should be weighed, and one should determine 
whether or not its weight is within normal limits. 

The amount of cow’s milk necessary in the preparation of 
the mixture should be determined. One and a half ounces 
of cow’s milk per pound of normal body weight at the baby’s 
age is a safe minimum for a healthy infant. It should be 
remembered that normal infants may require as much as 2 
ounces per pound of body weight. 

The total daily quantity of water required should be deter¬ 
mined, 3 ounces per pound (one-fifth the body weight) dur¬ 
ing the first six months and somewhat less, 2% ounces per 
pound (one-sixth the body weight) after this period. Suffi- 





MIXTURES ESTIMATED 


119 


cient water (or cereal water) should be added to the milk 
to bring the total quantity of mixture up to the day’s require¬ 
ments in fluids. 

Three grams of sugar, and later an additional 0.5 to 1 
gram of starch should be added for each pound of body 
weight. 

The curd should be made more digestible either by boiling, 
adding cereal water, or alkalizing the mixture. 

MIXTURES ESTIMATED ON THE BASIS OF 
CALORIC REQUIREMENTS 

The caloric needs of infants can be made the basis 
for formulating the constituents of their diet. 

The protein, fat, salts and carbohydrates must be so 
combined as to meet the infant’s needs in each of 
these elements. 

Forty-five calories per pound, or 100 per kilogram, 
may be considered as meeting the minimal daily require¬ 
ment of the average normal infant. Thin infants will 
require from 50 to 70 calories per pound (110 to 150 
per kilogram). 

The protein content should be supplied first; next 
the needs in fat, and last the carbohydrates. 

Protein .—The normal infant will require a minimum 
of 1.5 gm., which provides 6 calories per pound; this 
is furnished by the protein contained in iy 2 ounces of 
cow’s milk. Per kilogram, 3.5 gm. provide 14.3 calories, 
furnished by 100 c.c. of milk. 

Fat .—The needs in fat, 1.8 gm., or 16.5 calories, per 
pound, will, for most infants, be provided for by 1^2 
ounces of milk. Per kilogram, 4 gm., which provides 
37.2 calories, will be furnished by 100 c.c. of milk. 

Carbohydrates .—The sugar required in excess of the 
2 gm. (8.2 calories) provided by the milk, when \y 2 
ounces is fed per pound, will amount to 3 gm., or one- 
tenth ounce, for each pound of body weight. This 


120 PREPARATION OF MILK MIXTURES 


will furnish 12.3 calories, or a total of 20.5 calories 
inclusive of the sugar in the milk. Per kilogram, 
6.6 gm. of sugar must be added to the 4.5 gm. that 
is contained in 100 c.c. of milk. The infant will 
therefore receive 11 gm. of sugar per kilogram, 
which provides 45.5 calories. Therefore, in feeding 
\y% ounces of milk, plus one-tenth ounce of sugar, the 
following calories will be provided: protein, 6; fat, 
16.5, and sugar, 20.5, or a total of approximately 43 
calories for each pound of body weight. This requires 
considerable calculation in estimating the proper pro¬ 
portion of the ingredients and even more so if a second 
carbohydrate as starch is added. 

Table 20. —Amounts Required for an Infant Weighing 

Ten Pounds 

Ounces Calories 


Milk . 15 315 

Sugar . 1'/% 135 

Water . 15 ... 

Total . 450 


Table 21.— Amounts Required for an Infant Weighing 

Five Kilograms 


Gm. or C.c. Calories 


Milk . 500 350 

Sugar . 37.5 150 

Water .. 500 

Total . 500 


In feeding 100 c.c. of milk 41 with 6.6 gm. of sugar 
added, the infant will receive, for each kilogram: 
protein, 14.3 calories; fat, 37.2, and carbohydrates, 45.5, 
a total of 97 calories. We will therefore make use of 
the enumerated facts for calculating the initial diet 

41. Milk calculated as containing percentages as follows: protein, 3.5; 
fat, 4; sugar, 4.5. 



















REQUIREMENTS FOR INFANT 


121 


of a normal infant as follows: An infant weighing 
10 pounds will require 15 ounces of milk. Calculating 
his caloric needs at 45 per pound, his diet should contain 
a total of 450 calories. Of this 315 calories will be 
furnished by his milk. The remaining 135 are to be 
supplied by carbohydrates, sugar or sugar and starch. 
Jf sugar is used, 1 y 8 ounces will be required. Esti¬ 
mating 3 ounces of total fluids per pound of body 
weight, 15 ounces of water will be added as a diluent. 
The total formula will therefore be constituted as in 
Table 20. 

If estimated by the metric system, an infant weighing 
' 5 kg. requires 500 calories, and should receive the 
amounts given in Table 21. 

While in the case of average normal full-weight 
infants this method of calculating the diet works out 
satisfactorily, zvhen underweight infants are to be fed, 
the estimation of needed ingredients is less simple. It 
becomes even more complicated zvhen cereals and other 
foods are added to the diet. 

This method is also more complicated than the one 
previously recommended for analyzing diets that infants 
are taking. In comparing the two methods of estimat¬ 
ing the needed ingredients for the infant’s diet, the 
first is based on the amounts of each of the ingredients 
needed, and the second on the calories required. 

It is to be remembered that the quantities recom¬ 
mended under the heading Milk Dilutions with Added 
Carbohydrates, in the amounts suggested as minimums, 
furnish approximately 45 calories per pound, or 100 
per kilogram, of body weight—the proportions needed 
by the infant. In the feeding of underweight infants, 
the amounts ultimately needed are calculated on the 
basis of the estimated weight of the normal infant 

• 4 

of the same age and development. 


122 PREPARATION OF MILK MIXTURES 


UNDILUTED WHOLE MILK WITH CARBOHYDRATES 

While undiluted milk has been used with varying 
degrees of success by some of the continental pedia¬ 
tricians, on the whole it is not well borne before the 
fourth month of life. When undiluted whole milk 
is to be fed to a young infant, it should first be boiled 
in order to change the protein so that it will be precipi¬ 
tated in the infant’s stomach as a fine curd. Alkalizing 
the milk by the addition of sodium citrate or sodium 
bicarbonate also results in the formation of fine curds. 
If undiluted milk is used in the feeding of the very 
young infant, the size of the individual meal must of 
necessity be reduced under that recommended for 
diluted mixtures, or fewer meals must be given. Other¬ 
wise the caloric requirements of the infant will be 
exceeded. Water must be administered between feed¬ 
ings to meet the infant’s needs for fluids. 

While, as a routine measure of feeding, undiluted 
whole milk cannot be recommended, in some forms 
of vomiting and when gastric dilatation is present, 
small quantities of a concentrated food can often be 
fed to better advantage than larger quantities of milk 
dilutions. When carbohydrates are added, they should 
be in such amounts as are indicated by the infant’s 
weight and age. 

TOP-MILK DILUTIONS 

By this method a definite number of ounces of the 
upper part of milk which has stood for a number of 
hours is used as a basis for preparing the mixture. 

To carry out top-milk feeding successfully, the 
percentages of fat must be known which occur at 
various levels in 32 ounces (1 quart) of milk (con¬ 
taining 4 per cent, of fat) which has stood for six 
hours or longer. 

This method, endeavors to provide ample calories, 
and in this respect may be considered as successful. 



Fig. 9.—Tablespoonfuls: A, level; B, round; C, heaping. 







TOP MILK DILUTIONS 


123 


The chief advantages are that high fat and low casein 
mixtures can easily be prepared by the use of various 
dilutions of different layers of top-milk. With these 
mixtures there is the danger of feeding dilutions con¬ 
taining an excess of fat, not uncommonly reaching 
5 or 6 per cent, when the upper layers are used. Such 
high fat mixtures not uncommonly result in fat indi¬ 
gestion. The early advocates of this method recom¬ 
mended it on the basis of the low protein content of 
the mixture, believing that a high casein content fre¬ 
quently caused acute intestinal disturbances. In the 
light of our present knowledge, however, we know that 
the casein of milk boiled or alkalized, or mechanically 
divided by the addition of cereals, is easily digested and 

Table 22. —Fat Percentages 


Per Cent. 


Upper 16 ounces. 7 

Upper 20 ounces. 6 

Upper 24 ounces. 5 


causes nutritional disturbances only in exceptional 
cases. Owing to the tendency to use high dilutions, 
the sugar and salt content, more especially the latter, 
may be insufficient. This method of feeding has many 
advocates, and has given good results when its short¬ 
comings are recognized and the diets properly balanced. 

It will be of advantage to use the upper 16 ounces 
of the quart of milk (which will have a content of 
7 per cent, fat and 3.5 per cent, protein), in feeding 
certain selected infants who are not making satisfactory 
progress on the whole milk dilutions. When desirable, 
the 7 per cent, top-milk may be used in the mixture 
in amounts of iy 2 ounces per pound, or 100 c.c. per 
kilogram, as an alternative for whole milk. Such 
mixtures .will average about 3 gm. of fat per pound, 
or 6.6 gm. per kilogram of body weight. 








124 PREPARATION OF MILK MIXTURES 


While this amount of fat is in excess of the amount 
needed, only in exceptional cases will a healthy infant 
be upset by it. 

High fat mixtures are contraindicated in most infants 
with disturbed digestion, except those in which it is 
due to carbohydrate intolerance or protein sensitization. 
In these instances the fat will often replace, in part 
at least, the insufficiency of carbohydrate and protein. 

CREAM AND SKIMMED MILK MIXTURES 

By the use of 16 per cent, cream and skimmed milk 
as the basis for various milk modifications, a wide 
range of combinations of the various food elements may 
be obtained. By the use of cream and skimmed milk, 
an additional factor is added for calculating the percent¬ 
age content of the dilutions. This is, hozvever, not a 
great objection. The fact should be recognized that 
most physicians think of mixtures in terms of percent¬ 
ages without recognizing the possibility that one set of 
infants may receive large quantities of these dilutions 
in their day’s feedings, while another group, under 
different care, may receive much smaller quantities and 
fezver feedings of the same quality of mixture. If we 
accustom ourselves to think of the number of grams 
of fat, protein, carbohydrate and salts per kilogram or 
pound of body weight, it will in all probability offer 
the greatest possibilities of all the methods so far 
advocated. 

For feeding purposes, gravity cream (of which 
about 6 ounces or somewhat less may be obtained from 
a quart of a good quality of milk) contains fat, 16; 
protein, 3.5, and carbohydrate, 4.5 per cent. The 
skimmed milk may be obtained by carefully pouring or 
dipping off the cream. It should contain fat, 0; pro¬ 
tein, 3.5, and carbohydrate, 4.5 per cent. 


REQUIREMENT FOR AVERAGE INFANT 125 


The average infant should receive: fat, from 1.5 to 
2 gm.; protein, 1.5 grn., and as a minimum of added 
carbohydrate, 3 gm. (above that contained in the cream 
and skimmed milk), per pound of body weight. These 
will be obtained by the use of cream (16 per cent.), 
skimmed milk and sugar, the contents of which are 
given in Table 23. 

Table 23. —Contents of Cream, Skimmed Milk and Sugar 


Cream (16 per cent, fat).in 1 oz. 5 gm. fat 

Skimmed milk (3.5 per cent, protein).in 1 oz. 1 gm. protein 

Sugar (100 per cent, carbohydrate).in 1 oz. 30 gm. carbohydrate 


Table 24.— Amounts Needed 


For each gram of fat .%o oz., or 6 c.c. of cream 

For each gram of protein . i oz., or 30 c.c. of skimmed milk 

For each gram of carbohydrate . .. .%o oz., or 1 gm. of sugar 


Table 25. —Amounts for Each Pound of Body Weight 


Cream.4!o to $4o oz. (fat, from 1.5 to 2 gm.) 

Skimmed milk.1 /i oz. (protein, 1.5 gm.) 

Sugar.i/io oz. (carbohydrate, 3 gm.) 


Table 26. — Amounts for Each Kilogram of Body Weight 


Cream.20-27 c.c. (fat, from 3.3 to 4.4 gm.) 

Skimmed milk.100 c.c. (protein, 3.5 gm.) 

Sugar.6.6 gm. (carbohydrates, 6.6 gm.) 


The amounts needed are given in Table 24. 

In the mixture, the ingredients will be used in the 
amounts, per pound of body weight, given in Table 25. 

In the mixture, the ingredients will be combined in 
the amounts, per kilogram of body weight, given in 
Table 26. 

In underweight infants, the amounts would be cal¬ 
culated on the basis of initial weight at the beginning 


























126 PREPARATION OF MILK MIXTURES 


of feeding, but these would be increased gradually to 
the amounts necessary for a normal weight infant of 
the same age. 

Example: It is desired to feed a 10-pound baby, fat, 
20 gm.; protein, 15 gm., and carbohydrate, 30 gm., the 
amount required for one day’s food. These quantities 
would be supplied by cream, 4 ounces; skimmed milk, 
15 ounces; sugar, 1 ounce, and water, 11 ounces, bring¬ 
ing the total fluid to 3 ounces for each pound. The 
small excess of protein in the cream may be considered 
negligible. 

It will be noted that by considering the needs of the 
infant in terms of weight and forgetting the percentage 
content of the variable mixture, the danger of error is 
removed and the variation due to the individual physi¬ 
cian is done away with. At the same time this method 
of feeding becomes much simplified and retains all of 
its flexibility. 

There can be no doubt as to the accuracy of the 
modifications that can be obtained by this method of 
feeding. It has the disadvantage of requiring more 
calculation. In actual experience, the disadvantage to 
healthy infants of a possible relative excess of protein 
in mixtures made with simple dilutions of whole milk 
has been exaggerated. Practical experience presents 
convincing evidence that far more infants develop 
gastro-intestinal disturbance from feeding excessively 
rich cream mixtures. The greatest objection to high 
milk feeding is the resultant high protein constipated 
stool, which can be obviated by adding more sugar. 


CHAPTER XVIII 


FEEDING DURING DIFFERENT PERIODS OF 

THE FIRST YEAR 

The First Four Weeks of Life .—During the first two 
or three weeks of life, lesser relative quantities of food 
must be given than is recommended for later periods. 
During the first week, skimmed milk may be used in 
place of whole milk in amounts approximating 1 ounce 
to the pound of body weight. During the second week, 
the skimmed milk may be gradually replaced by whole 
milk, so that at some time during the third week the 
infant will be receiving one or more ounces of whole 
milk per pound of body weight. By the fourth week 
the infant can usually take the recommended 1% 
ounces of milk per pound of body weight. Beginning 
with the addition of 0.5 gm. of cane or milk sugar for 
each pound of body weight, these can be increased to 
1 gm. by the beginning of the second week, and to 2 or 
3 gm. by the beginning of the third week. At all times 
an endeavor should be made to administer at least one 
sixth of the infant’s body weight in water during the 
twenty-four hours. 

Such mixtures must of necessity show a lower caloric 
value than will meet the infant’s needs for growth 
and development, but, as suggested, the weak formulas 
should be used for mixtures for the new-born, and the 
strength increased according to the infant’s tolerance. 
When there is positive evidence that the mother will 
have an insufficient milk supply, the milk mixtures 
should be increased in strength somewhat more rapidly 
during the first two weeks, or larger quantities fed than 
outlined in Table 27. 

These mixtures should be boiled for three minutes 
over the direct flame, or a double boiler may be used. 


128 FEEDING DURING THE FIRST YEAR 


In the latter case the water in the outer vessel should 
boil for eight minutes. Boiled water should be added to 
make up the original quantity. 

Additional Foods from the Second to the Sixth 
Month. —The milk mixtures may be supplemented by 
the following additions to the diet: 

Cereal zvaters may be used as the diluent beginning 
with the second month. These are best made from 
whole cereals, as the dextrinized flours are devitalized. 
From one-sixtieth to one-thirtieth ounce (from 0.5 to 
1 gm.) of cereal for each pound of body weight may be 
used for making the amount of cereal water desired in 
the mixture. 

Table 27. — Diet for New-Born Infants During the 
First Four Weeks of Life 


7th, 10th, 

3d 5th 8th 11th 13th 

1st to to and and and 

48 4th 6th 9th 12th 14th 3d 4th 

Hrs. Days Days Days Days Days Wk. Wk. 

Milk (whole), ounces. .. .. 3 4 6 8 11 

Milk (skim), ounces. 6 8 5 4 4 2 

Sugar (cane), drams. 1 1 22234 6 

Water (boiled), ounces.... 16 10 8 8 8 8 8 10 

Calories in mixture. 15 81 118 148 158 215 250 321 

Feedings: 

Amount in ounces. 1 2 2.5 2.5 2.5 3 3 3.5 

Number daily. 6 6 6 6 6 6 6 6 

Intervals in hours. 4 4 44444 4 


Orange juice should be begun during the second 
month, beginning with one-quarter teaspoonful, diluted 
with water, twice daily, and increasing gradually until 
from one-half to 1 ounce is given by the end of the 
sixth month. 

Cod liver oil, either phosphorized or plain, should be 
started by the third month, beginning with 5 drops 
daily, and increasing to 1 teaspoonful twice daily, by 
the end of the sixth month. From spoon or dropper. 












CEREAL GRUELS 


129 


Cereal gruels (oatmeal, farina, cream of wheat) can 
be started by the beginning of the fifth month. They 
should be well cooked. The gruel can be added to one 
of the midmorning meals and later to the evening meal 
as well, starting with one-half teaspoonful and increas- 
ing gradually until 2 or 3 tablespoonfuls is given twice 
daily. 

BARLEY, OATMEAL AND RICE WATER 

One-sixtieth to 1/30 ounce (0.5 to 1.0 gm.) of cereal, whole 
or flour, for each pound of body weight, should be used in 
preparation of cereal zvater additions to the mixture. This 
should then be boiled down to the amount required to bring 
the day's mixture up to the proper amount. 

In using whole cereals and boiling for two hours in an 
open pan, use twice the amount of zvater needed for milk 
mixture to allow for evaporation. In 20 minutes’ boiling of 
the flours about Vs is lost. 

Flours—3 level tablespoonfuls = 1 ounce 
Grains—5 level tablespoonfuls = 1 ounce 

Soak the cereal grains in water overnight, pour off the water, 
add fresh water, and boil. Strain through fine cloth or 
sieve. Keep in icechest. 

CEREAL (OATMEAL, FARINA, CREAM OF WHEAT) 

2 tablespoonfuls cereal. 

Vo pint water. 

Vz pint milk. 

1 pinch salt. 

Cook in double boiler for one hour. Strain through a 
fine sieve. 

Additional Foods from the Sixth Month to the End 
of the First Year.—A broth and vegetable meal may be 
gradually substituted for the midday meal. This is 
best given as a vegetable soup. Feeding should begin 
with 1 ounce, gradually increased to 8 ounces, 1 ounce 
of milk mixture being omitted for each ounce of soup 
given. If less than a full feeding is given, the meal 
should be finished with sufficient milk mixture, from 
a second bottle, to make a full feeding. 


130 FEEDING DURING THE FIRST YEAR 


VEGETABLE SOUP (LAMB, CHICKEN, VEAL) 

% pound of lean meat cut into small pieces. 

1 potato, moderate size. 

1 carrot. 

2 stalks of celery. 

1 tablespoonful of pearl barley. 

2 tablespoonfuls of rice. 

2 quarts of water. 

1 pinch of salt. 

Finely divide the vegetables. Add vegetables, barley and 
rice to the water. Boil down to 1 quart, cooking three hours. 
Add salt. Rub vegetables through a fine sieve. When in 
season, spinach, tomato, peas and beans may be added to the 
soup stock, if desired. 

If kept in the upper compartment of the icechest against 
the ice, it may be used on the second day, but never later. 

Strained vegetables (spinach, carrots, potatoes) may 
be added in small portions by the eleventh or twelfth 
months as a side dish. There is little advantage in so 
using them before this time, for the vegetables in the 
soup, when rubbed through a fine sieve, are incorporated 
in the broth. 

Toast or dried bread crumbs may be added to the 
soup, if desired. 

Stewed fruits (apples and prunes) may be fed in 
small quantities by the end of the first year. So far as 
their accessory food value is concerned, they are 
inferior to orange juice. 

An infant should be taught to drink from a cup at 
least once daily in the latter part of its first year. This 
also holds true for the taking of its semisolids from a 
spoon. 

Iron medication may be begun in the second half of 
the first year or earlier by administering some of the 
organic iron preparations or small doses of inorganic 
preparations, such as iron and ammonium citrate, one- 
half grain, twice daily. 


APPLICATION OF RULES 


131 


EXAMPLES OF APPLICATION OF FEEDING RULES 
FOR WHOLE MILK DILUTIONS 

Normal Infant, Aged Three Months .—This infant 
should weigh 11 pounds (average birth weight, 7 
pounds, plus 4 pounds, representing a gain of 5 ounces 
weekly for thirteen weeks). 

Estimating 1% ounces of milk per pound of body 
weight, the result is 16% ounces of milk. 

Adding 3 gm. of cane sugar per pound of body 
weight, or 1 ounce for each 10 pounds, the result is 

I 1/10 ounces of sugar, or 2% level tablespoonfuls for 

II pounds. 


Table 28. —Amounts in Mixture for Normal Infant 

Aged Three Months 





Carbo- 

Salts 

Cal 


Protein 

Fat 

hydrate 

Gm. 

ories 

Milk (16.5 oz. — 495 c.c.). 

. . 17.3 

19.8 

19.8 

3.46 

346 

Water (16.5 oz. — 495 c.c.). 


• • • • 

• • • • 

• • • • 

• • • 

Sugar (1.1 cz. — 33 gm.). 

. 


33.0 

.... 

132 

Total mixture (33.0 oz. = 990 c.c.). 

. . 17.3 

19.8 

52.8 

3.46 

478 

For each pound of body weight.. 

1.575 

1.8 

4.8 

0.31 

43 


To make the total daily quantity 33 ounces (3 ounces 
of fluid per pound of body weight) it is necessary to 
add 16% ounces of water to the quantity of milk used. 

The baby should be fed five or six times daily, and 
should receive 5% or 6% ounces of the mixture at each 
meal. 

For practical purposes cow’s milk may be considered 
as averaging: fat, 4 per cent.; protein, 3.5 per cent.; 
carbohydrate, 4 per cent. 

The amounts of the various elements in the mixture 
and the grams of each and calories per pound of body 
weight in the milk mixture as given above, for a normal 
3-months old infant, weighing 11 pounds, are given in 
Table 28. 










132 FEEDING DURING THE FIRST YEAR 


We thus find that the infant fed on the prescribed 
diet receives 33 ounces of the mixture containing: fat, 
1.8 gm.; protein, 1.575 gm., and sugar, 4.8 gm. for each 
pound of body weight. 

The infant receives 43 calories per pound of body 
weight. 

Orange juice and cod liver oil should be included in 
the diet. 

It should be remembered that the needs of the indi¬ 
vidual infant are to be covered, and some infants need 
food of a higher caloric value for each pound of body 
weight. 

The mixture may readily be strengthened to meet 
indications for more fat and protein by the addition of 
milk or cream, and for more carbohydrates by the addi¬ 
tion of flour and sugar. With the addition of more 
milk, the water should be decreased. 

Infants inclined to vomit part of the feeding will 
often retain the food to better advantage by being fed 
small quantities ( 2 1 /2 ounces to the pound of body 
weight for the day) of a more concentrated mixture. 

Normal Infant, Aged Eight Months .—The infant 
should weigh 17 1 / 4 pounds (average birth weight 7 
pounds, which should be doubled in the first five 
months—14 pounds, plus a gain of 4 ounces a week for 
the remaining thirteen weeks—pounds). 

The following mixture will be prepared: 

One and one-half ounces of milk per pound of body weight, 
equals 26 ounces. 

Water to make 1 quart, equals 6 ounces. 

Sugar, 1V 2 ounces. As previously stated, the amount of 
sugar to be added is usually limited to 1 V 2 ounces, further 
carbohydrate needs being furnished by the addition of cereal 
waters or cereals. 

Starch, one-fourth ounce, or 8 gm. (approximately hw 
ounce, or 0.5 gm. per pound). 


AMOUNTS FOR NORMAL INFANT 


133 


This is to be fed in four feedings of 8 ounces each, 
and the fifth may be replaced by a soup and vegetable 
meal. A cereal feeding (from 2 to 4 tablespoonfuls) 
can also be given with one or two of the meals, part of 
the bottle of milk being poured over it, and the meal 
being finished with the remainder of the bottle. 

Further needs of the individual child may be supplied 
by concentrating the milk until 1 quart of whole milk 
is given, the carbohydrates in the mixture being gradu¬ 
ally decreased and given in another form, as gruel or 
custard. 

Underweight Infant, Aged Three Months, Weight 
Eight Pounds .—For beginning, this mixture should be 
prepared: milk, 12 ounces (1% ounces for each pound 


Table 29. — Amounts for Normal Infant Aged Eight Months 





Carbo- 

Salts 

Cal- 


Protein 

Fat 

hydrate 

Gm. 

ories 

Milk (26.0 oz. — 780 c.c.). 

27.3 

31.2 

31.2 

5.46 

546 

Water (6.0 oz. = 180 c.c.). 

• • • • 

• • • • 

• • • • 

• • • • 

• • • 

Sugar (1.5 oz. = 45 gm.). 

• • • • 

• • • • 

45.0 

• • • • 

180 

Starch (0.25 oz. — 8 gm.). 

• • • • 

• • • • 

8.0 

• • • • 

25 

Vegetable soup (8.0 oz. = 240 c.c.) . . . 

2.0 

4.5 

8.0 

2.4 

144 

Cereal (1 hpg. tblspoonful 1.0 — 30 gm.) 

.... 

• • • • 

15.0 

.... 

50 

Total feeding. 

29.3 

35.7 

107.2 

7.86 

945 

For each pound of body weight. 

1.7 

2.1 

6.2 

0.46 

55 


of present weight) ; water 12 ounces; cane sugar, 8/10 
ounce (lt /2 level tablespoonfuls, or 1/10 ounce or 3 gm. 
for each pound). This mixture is sufficient to make 
six feedings of 4 ounces each. 

To meet the requirements of this infant for growth 
and development, the needs of a full-weight infant of 
the same age must be approximated as rapidly as the 
infant’s tolerance for food permits. These increases 
can usually be made rapidly, if the infant is well other 
than for its underfeeding. The first increases are made 
in the carbohydrates by further addition of sugar and 
cereal water, until one-tenth ounce (3 gm.) per pound 












134 FEEDING DURING THE FIRST YEAR 


of sugar and from one-sixtieth to one-thirtieth ounce 
(0.5 to 1 gm.) per pound of cereal flour, are added in 
the form of cereal water. These increases are calcu¬ 
lated on the basis of average full weight (11 pounds for 
this age). The milk can be increased until from 1% 
to 2 ounces per pound of full weight, or from 16.5 to 22 
ounces for the total mixture is given. The total fluids 
should represent a minimum of 3 ounces per pound. 

If the infant is suffering from digestive disturbances, 
it may be necessary to begin with 1 ounce of milk or 
even less per pound of its present weight, that is, 8 
ounces or less in the mixture, adding only 1 or 2 gm. 
of sugar per pound. It must, however, be remembered 
that the infant will require 32 calories for each pound 
of body weight to sustain it; and if it is underfed for 
too long a period, inanition will result. 

With equal simplicity, errors in the mixture received 
by infants seen in the daily routine of practice may be 
interpreted almost at a glance. 

Example: An infant, aged 5 months, weight 12 
pounds, on bottle feedings of milk, 15 ounces; water, 
20 ounces; sugar, 2 ounces; feeding, 7 ounces, times, 5. 
Bowel movement three times daily. 

An average infant at this age should have doubled 
its weight to 14 pounds and should therefore be receiv¬ 
ing a minimum of 21 ounces of milk and 1 4/10 ounces 
of sugar. The error lies in the quantity of fat and pro¬ 
tein, which is too small in proportion to the quantity of 
sugar. This, in most instances, would account for the 
increased number of stools and subsequent stationary 
weight. 


CHAPTER XIX 


FEEDING AFTER THE FIRST YEAR 

i he average infant fed on cow’s milk mixtures will 
require as a minimum, per kilogram of body weight, 
during the later months of its first year, fat, 4 gm.; 
protein, 3.5 gm.; carbohydrates, 12 gm.; calcium oxid, 
0.17 gm., and a total water content in its day’s food 
including that contained in the milk equal to 125 c.c. 
per kilogram, which approximates one eighth of its 
body weight. (Per pound of body weight at 1 year: 
protein, 1.5 gm.; fat, 1.8 gm.; carbohydrates, 5.5 gm.; 
calcium oxid, 0.08 gm.; water, including that contained 
in the milk, equal to 2 ounces.) 


Table 30. —Amounts and Calories at One Year 
and at Six Years * 



Grams 

or Cubic 

Centimeters 

A 

per Kilogram 



r 


Carbo- 

Calcium 



Protein, 

Fat, 

hydrates, 

Oxid, Water, 


Gm. 

Gm. 

Gm. 

Gm. 

C.c. 

At 1 year. 

3.5 

4.0 

12.0 

0.17 

125 

At 6 years.... 

2.5 

3.0 

11.0 

0.17 

125 

Grams or Cubic Centimeters per Pound 

A 


At 1 year. 

r - 

1.5 

1.8 

5.5 

0.08 

60 

At 6 years.... 

1.2 

1.35 

5.0 

0.08 

60 


* The percentage distribution of the calories in the diet will approxi¬ 
mate: protein, 15.0; fat, 35.0; carbohydrates, 50.0. 

Note.—1 gram of protein = 4.1 calories; 1 gram of fat = 9.3 calo¬ 
ries; 1 gram of carbohydrates = 4.1 calories. 


A diet so constructed will furnish approximately 100 
calories per kilogram, or 45 calories per pound of body 
weight. 

In a study of the diets of a large group of nor¬ 
mal infants and children, Holt and his co-workers 
found that the food requirements of older infants and 
children showed a gradual decrease per kilogram of 
body weight after infancy. The fat taken diminished 
to 3 gm. per kilogram by the sixth year, while the pro- 










136 


FEEDING AFTER FIRST YEAR 


tein intake decreased to about 2.5 gm. per kilogram at 
6 years, and remained at this value or slightly below it 
until the end of growth. Of the protein, about 66 per 
cent, was in the form of animal protein from milk, 
eggs, meat, etc., the remainder being taken as vegetable 
protein. The carbohydrates should, to a large extent, 
be used to supplement the fat and the protein in the 
diet, the fat and protein, however, being first provided 
for. Holt believes on this basis that about 12 gm. of 
carbohydrates per kilogram at 1 year, with decreasing 
amounts to between 10 and 11 gm. per kilogram at 6 
years, will properly balance the diets. The average of 

Table 31. — Average Amounts of the Various Food 
Constituents Required by Children 


Age 


Weight 



Carbo- 


in 

r 

—-, 

Protein, 

Pat, 

hydrate, 


Years 

Pounds Grams 

Grams 

Grams 

Grams 

Calories 

1 

21.0 

9,513 

31.5 

37.8 

115.0 

952 

1V 2 

25.3 

11,460 

38.0 

45.5 

140.0 

1,153 

2 

28.0 

12,684 

39.2 

47.6 

154.0 

1,235 

3 

32.9 

14,905 

42.5 

52.6 

164.0 

1,836 

4 

36.1 

16,353 

46.93 

54.15 

180.0 

1,434 

5 

41.2 

18,663 

49.4 

57.7 

206.0 

1,584 

6 

45.0 

20,385 

54.0 

60.75 

225.0 

1,709 


all ages showed that about 50 per cent, of the carbohy¬ 
drate was taken in in some form of sugar and an equal 
amount of starch. (Per pound of body weight at 6 
years: protein, 1.2 gm.; fat, 1.35 gm.; carbohydrates, 
5.0 gm.) 

At 6 years the diets will approximate 85 calories per 
kilogram, or 38 calories per pound of body weight. 

The essential mineral salts will be contained in suf¬ 
ficient amounts to meet the child’s requirements in a 
well balanced diet. The total fluid requirements also 
decreased to an average of about one eighth of the body 
weight, 125 c.c. per kilogram, 60 c.c., or 2 ounces, per 
pound. 

While the average healthy Yi'avt \vA a 

greater amount of food per pound of body weight to 







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ADDITIONS AFTER FIRST YEAR 


137 


meet its needs for growth and development, the average 
percentage distribution of the amounts and calories will 
remain approximately the same at the different ages. 

ADDITIONS TO THE DIET AFTER THE FIRST YEAR 

The diet of a growing child should be so constituted 
as to contain sufficient quantities of the following: 

Whole Milk .—It has become our custom to postpone 
the feeding of whole milk without the addition of car¬ 
bohydrates until after the first year. While there is no 
contraindication to feeding whole cow’s milk by the 
beginning of the ninth month, or even earlier, when 
indicated, the milk being boiled or alkalized, the addi¬ 
tion of carbohydrates above the amount contained in 
whole milk is of advantage to the infant, both from 
the standpoint of its metabolic needs and in lessening 
the tendency toward constipation in the artificially fed 
infant. 

At no time is the infant to be fed more than 1 quart 
of whole cow’s milk in twenty-four hours. 

Unless the infant shows a tendency to take less than 
the required amount of milk in the form of a mixture, 
some water and 1 ounce of sugar are retained in the 
mixture until the infant is 1 year old. The water is 
gradually lessened from the tenth month so that by the 
end of the twelfth month only 2 to 4 ounces are 
retained— an amount sufficient to the sugar. The total 
fluid needs after the first year are a minimum of 2 
ounces per pound of body weight daily. Water may 
be given from a bottle two or three times daily, 
although not essential if the diet contains .sufficient to 
meet the infant’s needs. 

Cooked Cereals .—These should form a part of at 
least one or two meals. Those made from whole grain 
are the most valuable. The process of milling which 


138 


FEEDING AFTER FIRST YEAR 


removes the outer shell of the grain causes a loss of the 
greater part of the protein, mineral matter and vitamins. 

Toast and Bread Crusts .—Toast and bread crusts 
which have been spread with butter or jelly may be 
given at the end of one of the meals. 

Green Vegetables .—These are especially valuable 
because of their mineral salts and vitamins. They 
also give a needed bulk to the food, thereby tending to 
prevent constipation. They may be classed in two large 
groups—the tubers, such as potatoes, turnips, beets and 
parsnips—and the green vegetables. Of the latter 
group the leafy vegetables, such as spinach, lettuce, 
cabbage, sprouts, chard, cauliflower, asparagus, celery, 
turnip and beet tops, have an especially high mineral 
and vitamin content, as well as being rich in iron. 
Peas and beans have a high protein content, but this is 
not sufficient to replace the animal proteins in the diet 
of the growing child. Tomatoes are especially valuable 
as an antiscorbutic. Whenever possible, the water in 
which the vegetables are cooked should be retained, 
as it contains a large part of the mineral salts of the 
plants. 

Beef Juice .—Because of its high iron content, beef 
juice proves a valuable addition to the diet in the latter 
half of the first year. Beginning with one-half ounce, 
the quantity may be increased to 1 ounce or, at most, 2 
ounces daily. It can be mixed to advantage with the 
vegetable puree. 

Bacon .—A slice of crisp bacon containing very little 
lean may be given to advantage during the last months 
of the first year. 

Broiled Lamb Chops; Scraped Beef; Chicken and 
Fish .—These may be added to the diet during the sec¬ 
ond year. All meats should be finely divided. Beef 
steak, roast beef and lamb are better withheld until the 


FRUITS, EGGS AND DESSERTS 


139 


child shows a tendency to masticate its food. Even 
young children may be allowed to gnaw meat from 
bones, because of the beneficial influence on the teeth, 
gums and salivary glands. The flesh foods confer 
a desirable palatability on vegetable foods with which 
they are served. They should form only a limited part 
of the diet of young children. 

Fruits .—Fruit or fruit juices should always be con¬ 
sidered a necessary addition to the daily diet, and 
should form a part of at least one meal. They can be 
used to best advantage at the end of the meal. Raw 
fruits are of even greater value than cooked fruits. 
Scraped apple and banana may be given early in the 
second year. 

Honey and Jellies .—These may be spread on toast 
and bread. 

Eggs .—These contain every factor vital to the needs 
of the body for development, but nevertheless need to 
be combined with other foods to balance the diet prop¬ 
erly. They can be started at the beginning of the 
second year, either in the form of coddled egg or as egg 
custard. Very small amounts should be given at the 
first feeding until it is ascertained whether the infant 
has an idiosyncrasy to egg. After the fourteenth 
month, a half egg or more may be fed every second 
day. It may be alternated with beef juice or scraped 
beef. 

Cottage and Cream Cheese .—These may form a part 
of the diet at the end of the second year. 

Desserts .—Simple desserts, such as custard, pap, 
junket, gelatins, tapioca and rice pudding, are recom¬ 
mended during the second year. Only moderate quan¬ 
tities should be served, and then only at the end of the 
meal.* The child should be taught to consume the major 
items of the meal before taking the dessert. 


CHAPTER XX 


FACTS TO BE CONSIDERED IN FORMULATING 

THE DIET 

Children should be watched to see that they do not 
swallow their food without chewing it. It is stated 
that when we chew fibrous foods we exert a pressure 
of one hundred or more pounds on the teeth, and this 
insures a good circulation of blood in the inner part, 
and is an important factor in developing the teeth and 
jaws. It is especially important for children that the 
last article eaten should be of such a nature as to 
cleanse the teeth. 

Soft foods require little or no mastication, and there¬ 
fore call forth a minimum secretion of saliva and are 
of no aid in developing the jaws and preserving the 
teeth. 

Green vegetables require mastication, and therefore 
have a beneficial effect in the development of the 
teeth; and, because of their bulk and some of their 
constituents, they stimulate intestinal peristalsis. Bread- 
stuffs and meat have an added value in that they require 
mastication. 

Carbohydrate residues tend to favor decay more 
than do meat and vegetable particles. It is therefore 
of great advantage to finish the meal with fruits, vege¬ 
tables or hard crusts rather than with soft desserts and 
other sweets. 

Eating Habits .—Young children should be fed at 
regular hours. Incessant eating is one of the greatest 
handicaps to proper development. The child should 
be taught what kind of a diet best promotes health, 
and encouraged to eat the food placed before it by the 
good example of the other members of the family. 
Eating between meals necessarily will result in a loss 
of appetite, and sooner or later the result becomes 
manifest in the child’s lack of development. It often 


PSYCHOLOGY OF CHILD FEEDING 


141 


becomes necessary to cultivate slowly a liking for spin¬ 
ach and other vegetables. It is always to be remem¬ 
bered that milk, cereals and vegetables must take 
precedence over meats and sweets. The diet should be 
so constructed in the individual case as to overcome 
any tendency toward constipation. 

Overeating .—This is less likely to occur when the 
number of meals is limited to stated hours. The com¬ 
bination of overeating and constipation is probably the 
most important factor in the development of anorexia 
in childhood. It has been established that a reverse 
peristalsis may follow, with a flowing of the contents 
of the intestine back toward the stomach, with nausea 
and belching. This abnormal nervous reaction soon 
results in repugnance to all foods. Carbohydrate fer¬ 
mentation and protein decomposition in the intestinal 
tract • aggravate the condition. 

Poor Hygienic Conditions .—Lack of fresh air, too 
limited exercise and sleeping in closed rooms all have 
a detrimental influence on appetite, digestion and 
physical development. 

PSYCHOLOGY OF CHILD FEEDING 

Two factors are of prime importance—inheritance 
and environment. In order to meet the needs of the 
many children with whom the physician comes in con¬ 
tact, he must remember that individual children develop 
and grow at different rates, and that many, by reason 
of bad heredity, are neurotic and anemic; and when 
improper feeding is added to their difficulties, the 
resulting problem calls for tact in its solution. 

The high tension, nervous child is frequently the 
offspring of neurotic parents. A nervous mother has a 
direct influence on the development of the infant. In 
such an environment, unless the child is an exceptional 
one, there is great liklihood of the daily routine being 
broken to meet the whims of the child. The introduc- 


142 CONSIDERATIONS IN FORMULATING DIET 


tion of new foods and changes in the methods of 
administering them often results in a rebellious atti¬ 
tude on the part of the child. These tendencies should 
be recognized in early infancy, and the importance of 
counteracting them impressed on the mother. The 
attitude that she is to assume toward the infant must 
be definitely explained, and, on her readiness to 
cooperate, the physician should base his opinion as to 
her fitness to have charge of her own child. If the 
child is placed in care of a nurse, the physician must 
painstakingly explain the requirements and handicaps 
of the individual case. It is self evident that a neurotic 
attendant does not improve the situation. 

The modern tendency to provide an endless variety 
in foods for the growing child leads it to acquire false 
dietetic inclinations. The same may be stated about 
the more recent tendency to keep detailed notes on the 
calories consumed by the family. This habit in many 
instances is carried to the extreme, thus influencing the 
mother’s better judgment. It should be the physician’s 
duty to provide a suitable diet, and the mother’s to 
serve it. To accomplish the desired result the child 
should be taught to enjoy proper exercise—rest periods 
should be maintained and good hygienic surroundings 
provided. 

The appetite must not be considered a safe guide in 
the selection of food. The physician should consider 
it sound practice to prescribe what the child should eat, 
and the mother’s duty to serve it. 

A complete change of surroundings, such as moving 
from the city to the country, away from the influence 
of the parents, placing the child in charge of a proper 
attendant, commonly results in a speedy improvement 
in the general condition and stabilization of the nervous 
system. 

Temporary hospitalization is sometimes necessary if 
the more ideal course cannot be realized. 



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CHAPTER XXI 


SUGGESTED AVERAGE DIETS FROM SIX 
MONTHS TO SIX YEARS, INCLUSIVE 

The diets which are given in the following tables 
have been figured on a maximum basis. The general 
conditions surrounding the individual child must there¬ 
fore be taken into consideration; otherwise, some of 
the amounts and varieties may be found excessive. 


DIET 
6 a. m. 

8 a. m. 

10 a. m. 


2 p. m. 


6 p. m. 
10 p. m. 


FROM SIX TO NINE MONTHS 

Breast or milk mixture, 8 ounces. 

(Milk mixture: milk, from 22 to 28 ounces; 
sugar, \ l / 2 ounces; water to make from 32 
to 40 ounces as needed.) 

Orange juice, 2 or 3 tablespoonfuls (sweet¬ 
ened). 

Cod liver oil, one or two teaspoonfuls. 

Breast or milk mixture, 8 ounces. 

Cereal (farina, cream of wheat or oatmeal) 
1 or 2 rounded tablespoonfuls. 

The cereal may be added to the bottle, or 
some of the milk mixture may be added to 
the cereal—feeding by spoon. 

Vegetable soup or milk mixture, total, 8 
ounces. 

When starting the soup feeding, first replace 
1 ounce of milk with 1 ounce of soup and 
feed from a second bottle; gradually in¬ 
crease the soup and diminish the milk until 
the entire meal of soup is given. 

Breast or milk mixture, 8 ounces. 

Cereal (as at 10 a. m.). 

Breast or milk mixture, 8 ounces. 


DIET 
6 or 7 a. m. 


NINE TO TWELVE MONTHS 

Milk mixture, 8 ounces. Milk, 6 ounces; 
water, 2 ounces; sugar, 2 level teaspoon¬ 
fuls. 


8:30 a. m. Orange or prune juice, 2 or 3 tablespoonfuls. 

If preferable, this may be given with the 
10 a. m. or 2 p. m. meal. 

10 a', m. Milk mixture, 8 ounces. Cereal (farina, oat¬ 
meal, etc.), from 2 to 4 tablespoonfuls. 


144 


SUGGESTED DIETS 


2 p. m. Vegetable or cream soup, from 6 to 8 ounces, 
and 

Zwieback or toast (crumbled), Vst slice, 
or 

Milk, from 2 to 4 ounces. 

Vegetables: strained spinach, carrot or squash 
(early), potato, peas, asparagus, celery 
(toward end of first year), 1 or 2 rounded 
tablespoonfuls, with 

Beef juice, from x /z to 1 ounce. 

Stewed fruit (prunes or apples), 1 tablespoon¬ 
ful. 

6 p. m. Milk mixture, 8 ounces. 

Cereal (farina, oatmeal, etc.), from 3 to 4 
tablespoonfuls, with sugar, 1 teaspoonful. 


DIET TWELVE TO FOURTEEN MONTHS 

7 a. m. Milk, 8 ounces. 

Cereals (farina, oatmeal, etc.), 3 or 4 table¬ 
spoonfuls with sugar, 1 teaspoonful; pour 
some of milk over cereal. 

Bacon, 1 slice. 

Orange juice, prune pulp or apple sauce, 1 
or 2 ounces. 


11 a. m. or 
12 noon 


3. p. m. 
6 p. m. 


Vegetable or cream soup, from 6 to 8 ounces, 
and 

Zwieback or toast (crumbled), 1 slice, plus 
one-fourth cube of butter, 

or 

Milk, from 2 to 4 ounces. 

Vegetables, 1 or 2 tablespoonfuls, 
with 

Beef juice, from % to 1 ounce, or one-half of 
a coddled egg. 

Dessert, corn-starch pudding or junket, 2 
tablespoonfuls, 
or 

Stewed fruit (prunes or apples), 1 or 2 table¬ 
spoonfuls. 

Milk, 6 ounces. 

Toast, zwieback or bread, one-half slice. 

Butter, one-fourth cube. 

Milk, 6 ounces. 

Cereal (farina, oatmeal, etc.), 2 or 3 table¬ 
spoonfuls, with sugar, 1 teaspoonful. 

Stewed fruits, 1 tablespoonful. 


DIET FOURTEEN TO EIGHTEEN MONTHS 145 


COMPUTATION OF DIET: AGE, FOURTEEN MONTHS; 
WEIGHT, TWENTY-THREE POUNDS 


Pro- Carbo- 

tein, Fat, hydrate, Calo- 
Food Quantity Gm. Gm. Gm. ries 

Milk. 20 oz. 20.0 24.0 30.0 420 

Orange juice. 2 oz. 0.6 0.1 8.0 40 

Cereal (farina). 6 rd. tbsp. 3.0 0.6 21.0 102 

Soup (vegetable). 6 oz. 6.75 0.3 8.25 64 

Toast. 2 Slices 4.4 0.64 24.50 122 

Butter. % cube 0.08 6.50 0.6 60 

Bacon. 1 slice 0.4 1.8 0.0 18 

Sugar. 2 level teasp. 0.0 0.0 10.0 41 

Pudding (custard). 2 rd. tbsp. 4.8 5.0 14.0 122 


Total for 23 pounds. 40.03 38.94 116.35 989 

Per pound. 1.74 1.69 5.0 43 


DIET FOURTEEN TO EIGHTEEN MONTHS 


7 or 8 a. m. 


12 noon 


3 p. m. 
6 p. m. 


Milk, 8 ounces. 

One-half slice of toast, bread or roll, with one- 
fourth cube of butter. 

Orange juice, 2 ounces, or prune pulp or apple 
sauce, 1 tablespoonful. 

Cereals (farina, oatmeal, etc.), 3 or 4 table¬ 
spoonfuls with sugar, 1 level teaspoonful. 
Pour some of milk over cereal. 

Bacon, 1 or 2 slices, or one half of 1 coddled 
egg. 

Vegetable or cream soup, from 6 to 8 ounces, 
or milk, from 3 to 5 ounces. 

Zwieback or toast (crumbled), 1 slice, with 
butter, X A cube. 

Vegetables: One or two tablespoonfuls each 
of two fresh vegetables. 

Beef juice, 1 ounce, or 

Scraped beef, 1 tablespoonful, or 

1 small lamb chop (lean portion), or 

Minced chicken, 1 tablespoonful. 

Dessert: Corn-starch pudding, or junket, 2 
tablespoonfuls, 
or 

Stewed fruit (prunes or apples) 2 tablespoon¬ 
fuls. 

if desired. 

Milk, 6 or 8 ounces. 

Toast, zwieback, small slice, or one cookie. 

Milk, 8 ounces. 

Cereal, 3 tablespoonfuls: farina, cream of 
wheat, oatmeal, etc., with sugar, 1 level tea¬ 
spoonful. 

Bread or toast, one-half slice, with one-fourth 
cube of butter. 

Stewed fruit, 1 tablespoonful. 






















146 


SUGGESTED DIETS 


DIET EIGHTEEN TO TWENTY-FOUR MONTHS 


7 or 8 a. m. Milk, 8 ounces. 

1 slice toast, bread or roll, with one-fourth 
cube of butter. 

Cereals (farina, oatmeal, etc.), 3 or 4 table¬ 
spoonfuls, with sugar, 1 level teaspoonful; 
some of milk over cereal, and 1 tablespoon¬ 
ful cream. 

Bacon, 2 slices, or 1 coddled egg. 

Orange juice, 2 ounces; prune pulp, baked 
apple, apple sauce or scraped pineapple, etc., 
1 tablespoonful. 

12 noon Vegetable or cream soup, 6 ounces, or milk, 
from 4 to 6 ounces. 

Zwieback or toast (crumbled), 1 slice, with 
one-fourth cube of butter. 

Vegetables: One or two tablespoonfuls each 
of two fresh vegetables. 

Beef juice, V/z ounces, or 

Scraped beef, 2 tablespoonfuls, or 

1 small lamb chop, or 

Minced chicken, 2 tablespoonfuls. 

Dessert: Corn-starch pudding, or junket, 4 
tablespoonfuls, 
or 

Stewed fruits, 2 tablespoonfuls. 

3 p. m. if desired. 

Milk, 6 or 8 ounces. 

1 slice of toast, bread or roll with one-fourth 
cube of butter or 2 or 3 cookies. 


6 p. m. Milk, 6 ounces. 

Cereals, 3 or 4 tablespoonfuls : farina, cream 
of wheat, oatmeal, etc. 

Bread or toast, with honey or jelly, one-half 
tablespoonful, with one-fourth cube of 
butter. 


DIET TWO TO FOUR YEARS 

7 or 8 a. m. Milk or cocoa, 8 ounces. 

Cereals (cooked preferable), from 4 to 6 table¬ 
spoonfuls, with sugar, 1 level teaspoonful, 
some of milk over cereal, and 1 or 2 table¬ 
spoonfuls of cream. 

Bacon, 2 slices, 
or 

Egg, 1 coddled, poached or scrambled. 

Bread or toast, 1 slice. 

Butter, % cube. 


DIET TWO TO FOUR YEARS 


147 


Fruit: Orange juice, grapefruit juice, prune 
pulp, baked apple, apple sauce, or scraped 
pineapple, etc., 2 tablespoonfuls. 

12 noon Milk or vegetable soup, 6 ounces. 

Vegetables: One tablespoonful each of two 
fresh vegetables. 

Beef juice, 1 V 2 ounces, 
or 

Lamb chop (1), fish, chicken, scraped steak 
(V 3 pat) sweetbreads, etc. 

Bread or toast, 1 slice. 

Butter, V 4 cube. 

Dessert: Corn-starch pudding, custard, tapi¬ 
oca, rice, junket, etc., 2 tablespoonfuls, 
or 

Stewed fruits, from 2 to 4 tablespoonfuls, 
or 

Fresh fruits : V 2 apple, 1 peach, plum or pear, 
V 2 grapefruit or banana. 

Tea biscuit, lady fingers, etc., 1 or 2. 

6 p. m. Milk, 6 ounces. 

Cereal (3 or 4 tablespoonfuls) : farina, cream 
of wheat, oatmeal, etc.; sugar, 1 level tea¬ 
spoonful ; some of milk over cereal, and 1 
or 2 tablespoonfuls of cream. 

Bread or toast, 1 slice, with honey, syrup or 
jelly, 1 tablespoonful. 

Butter, V 4 cube. 

Stewed fruit, 1 or 2 tablespoonfuls. 


COMPUTATION OF DIET; AGE, FOUR YEARS; WEIGHT, 

THIRTY-SIX POUNDS 




Pro- 


Carbo- 




tein, 

Fat, 

hydrates, 

Calo- 

Food 

Quantity 

Gm. 

Gm. 

Gm. 

ries 

Milk. 

14 oz. 

14.0 

16.8 

21.0 

294 

Orange juice. 

2 oz. 

0.6 

0.1 

8.0 

40 

Cereal (farina). 

10 rd. tbsp. 

5.0 

1.0 

35.0 

170 

Egg. 

One 

6.6 

6.0 

0.0 

80 

Toast. 

3 slices 

6.6 

0.96 

36.0 

183 

Butter. 

% cube 

0.12 

9.75 

0.9 

90 

Vegetables—Potato. 

1 rd. tbsp. 

0.8 

0.03 

17.0 

32 

Spinach. 

1 rd. tbsp. 

1.1 

0.2 

1.4 

12 

Lamb chop. 

One 

6.5 

9.0 

0.0 

107 

Rice pudding. 

2 rd.tbsp. 

4.2 

3.4 

17.2 

120 

Stewed fruit. 

4 rd.tbsp. 

0.48 

0.8 

36.0 

152 

Sugar. 

1 level teasp. 

0.0 

0.0 

5.0 

20 

Lady fingers. 

Two 

1.0 

0.6 

8.5 

43 

Total for 36 pounds. 


47.00 

48.64 

176.0 

1,343 

Per pound. 


1.3 

1.35 

5.0 

37.3 
























148 


SUGGESTED DIETS 


DIET FOUR TO SIX YEARS 

7 or 8 a. m. Milk or cocoa, 8 ounces. 

Cereals (cooked preferable), from 4 to 6 table¬ 
spoonfuls, with sugar, 1 teaspoonful, and 
cream, 2 tablespoonfuls. 

Bacon, 2 or 3 slices, 
or 

Egg, 1 coddled, poached or scrambled. 

Bread or toast, 1 slice. 

Butter, V± to Vz cube. 

Fruit: Orange juice, grapefruit juice, 2 ounces, 
prune pulp, baked apple, apple sauce, or 
scraped pineapple, etc., 2 to 3 tablespoon¬ 
fuls. 

12 noon Milk or vegetable soup, 6 ounces. 

Vegetables: Two tablespoonfuls each of 2 
fresh vegetables. 

Meat: Lamb chop, 1; scraped steak, V 2 pat; 
fish, chicken, lamb, or beef, 1 slice. 

Butter, % to Vz cube. 

Dessert: Corn-starch pudding, custard, tapi¬ 
oca, rice junket, gelatin or other simple 
dessert, from 2 to 4 tablespoonfuls. 

Fresh fruit: One-half apple, 1 peach, plum or 
pear, V 2 grapefruit or banana. 

Tea biscuit, lady fingers, 1 or 2, or light cake, 

. 1 slice. 

6 p. m. Milk, from 6 to 8 ounces. 

Cereals, from 4 to 6 tablespoonfuls, with 
sugar, 1 level teaspoonful, and cream, 2 
tablespoonfuls. 

Bread or toast, 1 slice. 

Butter, V 4 to Vs cube; jelly, syrup or honey, 
1 tablespoonful. 

Stewed fruit, 2 or 3 tablespoonfuls. 

Note. —Salads: Fruit, lettuce, tomato, etc., may be added 
to the diet at this age. 

Cheese: Cottage and cream cheese may be given in mod¬ 
erate quantities. 


FOOD VALUE OF INDIVIDUAL SERVINGS 149 


FOOD VALUE OF INDIVIDUAL SERVINGS * 







Car- 

Calo- 

Cal. 


Approxi- 


Pro- 


bohy- 

ries in 

per 


mate Weight, 

tein, 

Fat, 

drates, 

Por- 

100 

Foods 

Quantity 

Gm. 

Gm. 

Gm. 

Gm. 

tion 

Gm. 

MEATS (Cooked) 








Beef juice. 

1 oz. 

30 

1.5 

0.18 

0.0 

8 

26.5 

Beef roast. 

4 x 4x 1 /£" 

100 

22.0 

28.0 

0.0 

350 

350 

Beefsteak, round— 

4x4x%" 

100 

28.0 

8.0 

0.0 

185 

185 

Beef tenderloin. 

.2%x2%xl" 

100 

23.5 

20.4 

0.0 

286 

286 

Beef, scraped. 

4 in. pat 

100 

21.0 

10.6 

0.0 

185 

185 

Veal roast. 

, Thin slice 

36 

9.9 

0.43 

0.0 

44 

122 


4X4" 







Lamb chops. 

Flesh of one 

30 

6.5 

9.0 

0.0 

107 

360 

Lamb roast. 

3y 2 x3!4xi4" 

37 

7.3 

4.7 

0.0 

71 

192 

Mutton, roast leg...3%x3^xy 4 " 

37 

9.2 

8.3 

0.0 

112 

300 

Ham, boiled. 

. Thin slice 

30 

6.0 

6.7 

0.0 

85 

283 


4x3" 







Bacon, fried. 

. Thin slice 

4 

0.4 

1.8 

0.0 

18 

450 

Chicken, roast. 

, Thin slice 

35 

10.7 

1.5 

0.0 

56 

160 


3^x4" 







Meat, stewed with 







vegetables. 

1 cup. 8 oz. 

240 

11.0 

12.0 

26.0 

260 

108 

FISH (Cooked) 








Blueflsh. 

, Thin slice 

75 

19.4 

3.4 

0.0 

108 

144 


3x3" 







Cod. 

, Thin slice 

75 

16.5 

0.15 

0.75 

70 

93 


3x3" 







Oysters, uncooked... 

6 oysters 

80 

4.8 

1.0 

2.6 

39 

50 

SOUPS 








Homemade: 








Beef. 

4 oz. 

120 

5.3 

0.5 

1.3 

32 

26 

Bean. 

4 oz. 

120 

3.8 

1.7 

11.0 

78 

65 

Chicken. 

4 oz. 

120 

12.6 

1.0 

3.0 

72 

61 

Cream vegetable.. 

4 oz. 

120 

4.5 

0.2 

5.5 

43 

36 

Canned: 








Asparagus, cream of 4 oz. 

120 

3.0 

4.0 

6.6 

76 

63 

Chicken. 

4 oz. 

120 

4.2 

0.12 

1.8 

24 

20 

Oxtail. 

4 oz. 

120 

4.8 

1.56 

5.16 

55 

46 

Pea. 

4 oz. 

120 

4.32 

0.84 

9.12 

63 

52 

Tomato. 

4 oz. 

120 

2.16 

1.32 

6.72 

49 

41 

Vegetable. 

4 oz. 

120 

3.48 

0.0 

0.6 

17 

14 

EGGS 








Whole egg, boiled... 

One egg 

50 

6.6 

6.0 

0.0 

82 

164 

Yolk, boiled. 

Yolk of one 

18 

2.9 

6.0 

0.0 

66 s 

370 

Yolk, raw. 








White, boiled. 

One egg 

32 

4.16 

0.06 

0.0 

16 

55 

White, raw. 








Omelette.3 eggs, 3 tbsp. 

150 

20.0 

28.0 

3.0 

350 

240 

milk, 1 teasp. butter 







DAIRY PRODUCTS 








Milk. 

1 oz. 

30 

1.0 

1.2 

1.5 

21 

70 

Cream. 

1 oz. 

30 

0.75 

5.5 

1.35 

58 

190 

Buttermilk. 

1 oz. 

30 

0.75 

1.5 

1.5 

10 

33 

Butter. 

1-in. cube 

15 

0.15 

13.0 

1.15 

120 

800 

Cheese. American— 

1-in. cube 

20 

5.7 

7.0 

0.06 

90 

450 

Cheese. Camembert.l full teasp. 

20 

4.2 

4.3 

0.0 

58 

290 

Cheese, cottage. 

1-in. cube 

20 

4.0 

0.2 

1.0 

25 

125 


* In computing these tables, free use has been made of U. S. Dept, of 
Agriculture Bulletin 28 (Atwater and Bryant), Farmers’s Bulletin 142 
(Atwater), E. A. Locke, On Food Values, D. Appleton & Co., New York, 
and Amye Pope, A Dietary Computer, G. P. Putnam’s Sons, New York. 





































150 


FOOD VALUE TABLES 


FOOD VALUE OF INDIVIDUAL SERVINGS—Continued 



Approxi- 


Pro- 


Car- 

bohy- 

Calo¬ 
ries in 

Cal. 

per 


mate Weight, 

tein, 

Fat, 

drates, 

Por- 

100 

Foods 

Quantity 

Gm. 

Gm. 

Gm. 

Gm. 

tion 

Gm. 

CEREALS 

Farina (boiled). 1 rd. tbsp. 

Cream of wheat 

30 

0.5 

0.1 

3.5 

17 

57 

(boiled). 


30 

0.5 

0.12 

3.5 

17 

57 

Hominy (boiled).. 

.. 1 rd.tbsp. 

30 

0.7 

0.06 

5.4 

25 

82 

Oatmeal (boiled).. 

.. 1 rd. tbsp. 

30 

0.8 

0.35 

3.3 

20 

60 

Com flakes. 


3 

0.3 

0.04 

2.3 

11 

365 

Rice (boiled). 


30 

0.8 

0.03 

7.5 

34 

110 

Macaroni (boiled). 

.. 1 rd. tbsp. 

30 

1.0 

0.5 

5.2 

30 

100 

Shredded wh. biscuit One 

30 

3.0 

0.4 

23.0 

109 

365 

BREADS 

White. 

sy 2 x3xy 2 " 

30 

2.76 

0.39 

15.9 

80 

268 

Wheat, whole. 

Slice 

3%x3%x%" 

42 

4.0 

0.38 

21.0 

106 

251 

Corn. 

3x2x%" 

39 

3.0 

1.8 

18.0 

100 

260 

Toast. 

3x3xy 2 " 

20 

2.2 

0.32 

12.24 

61 

305 

Cream toast. 


VO 

9.0 

7.3 

18.5 

160 

230 

Zweiback. 

.2 slices, small 

15 

1.5 

1.5 

11.0 

65 

434 

Rolls, French. 


39 

3.3 

1.0 

21.7 

112 

287 

Rolls, Vienna. 

.. One roll 

45 

3.8 

1.0 

25.0 

128 

284 

CRACKERS 

Soda. 


6 

0.59 

0.55 

4.38 

25 

424 

Saltines. 


3 

0.32 

0.38 

2.0 

13 

492 

Graham. 


8 

0.8 

0.75 

5.9 

34 

429 

Oatmeal. 

Cookies. 


10 

1.18 

1.11 

6.9 

43 

434 

SANDWICHES 

Chicken. 


70 

8.6 

3.8 

22.5 

165 

235 

Egg. 


100 

9.6 

12.7 

34.5 

300 

300 

Ham. 


70 

7.2 

10.0 

26.6 

233 

332 

VEGETABLES 

Cooked: 

Beans (baked)... 


33 

2.45 

3.0 

7.4 

68 

204 

Beans, lima. 

.. 1 rd. tbsp. 

20 

1.6 

0.14 

6.0 

32 

160 

Beans, string.... 


30 

0.25 

0.33 

0.75 

7 

23 

Beets. 


35 

0.8 

0.03 

2.6 

14 

40 

Cabbage. 


30 

0.5 

0.09 

1.8 

10 

33 

Carrots. 


33 

0.2 

0.05 

1.17 

6 

18 

Cauliflower. 

.. 1 rd. tbsp. 

20 

0.35 

0.09 

0.95 

6 

30 

Turnips. 


30 

0.4 

0.05 

2.5 

12 

40 

Spinach. 


30 

1.1 

0.2 

1.45 

12 

40 

Cora (cut off ear) 1 rd. tbsp. 

30 

0.8 

0.36 

5.8 

30 

100 

Onions. 

.. 1 rd. tbsp. 

30 

0.4 

0.06 

1.7 

9 

30 

Peas. 

.. 1 rd. tbsp. 

30 

2.1 

0.1 

4.6 

28 

92 

Asparagus tips.. 

.. 1 rd. tbsp. 

30 

0.6 

0.05 

1.0 

7 

23 

Potato, white... 

.. 1 rd. tbsp. 

30 

0.8 

0.03 

7.0 

32 

106 

Potato, sweet... 

.. 1 rd. tbsp. 

30 

0.6 

0.2 

8.4 

38 

125 

Potato (baked). 

.. 1 med. size 

80 

2.1 

0.06 

17.5 

79 

100 

Uncooked: 

Celery. 

.. 2 stalks 

20 

0.22 

0.02 

0.66 

4 

20 

Cucumbers. 

. .6 thin slices 

30 

0.24 

0.06 

0.93 

5 

17 

Lettuce. 

. .Smallheart 
3" diameter 

50 

0.60 

0.15 

1.45 

11 

22 

Radishes. 

.. 4 med. size 

35 

0.45 

0.03 

2.03 

10 

30 

Tomatoes. 

.. 1 med. size 

100 

0.90 

0.40 

3.90 

23 

23 












































FOOD VALUE OF INDIVIDUAL SERVINGS 151 


FOOD VALUE OP INDIVIDUAL SERVINGS—Continued 



Approxi- 


Pro- 


Car- 

bohy- 

Calo¬ 
ries in 

Cal. 

per 


mate Weight, 

tein, 

Gm. 

Fat, 

drates, 

Por- 

100 

Foods 

Quantity 

Gm. 

Gm. 

Gm. 

tion 

Gm. 

VEGETABLES 

Canned: 

Asparagus. 

long 

93 

1.67 

0.18 

3.06 

20 

22 

Beans, baked navy 1 heaping 

tbsp. 

40 

2.7 

1.0 

7.5 

50 

125 

Corn. 

tbsp. 

50 

1.4 

0.6 

9.5 

50 

100 

Tomato. 

tbsp. 

35 

0.42 

0.07 

1.4 

8 

23 

FRUITS 

Uncooked 

Apples. 


125 

0.5 

0.6 

18.0 

80 

64 

Bananas. 


110 

1.43 

0.66 

24.0 

108 

100 

Cantaloupe. 

... y 2 melon 

465 

1.4 

0.0 

21.4 

93 

20 

Grapefruit. 


300 

2.4 

0.6 

30.0 

140 

47 

Oranges. 

... 1 medium 

5 oz. juice 

250 

1.5 

0.25 

21.0 

96 

37 

Peaches. 


80 

0.56 

0.08 

7.5 

33 

40 

Pears. 


150 

0.9 

0.75 

16.0 

95 

64 

Plums. 


35 

0.32 

0.0 

5.69 

29 

81 

Strawberries.... 


100 

1.0 

0.60 

7.4 

40 

40 

Watermelon— 

... Large slice 

300 

0.6 

0.3 

8.0 

39 

13 

Canned: 

Apricots. 

... 2 halves 
plus tbs. sirup 

80 

0.72 

0.0 

13.8 

58 

72 

Peaches. 

1 tbs. sirup 

80 

0.56 

0.08 

8.6 

37 

46 

Pears. 

3 tbs. sirup 

110 

0.33 

0.33 

19.8 

83 

76 

Cooked: 

Apple (baked).. 

... 1 large 

(4 oz.) 

120 

0.6 

0.6 

30.0 

128 

100 

Apple sauce. 


30 

0.12 

0.2 

9.0 

38 

125 

Prune pulp. 


30 

0.45 

0.0 

9.5 

40 

132 

Marmalade, orange 1 rd. tbsp. 

30 

0.2 

0.03 

26.0 

105 

345 

Jelly, currant... 


30 

0.38 

0.0 

27.0 

113 

370 

Dried: 

Apricots. 


41 

1.9 

0.4 

25.0 

114 

284 

Dates. 


40 

0.8 

1.0 

30.0 

133 

320 

Figs. 

5 large 

100 

4.2 

0.3 

72.0 

315 

315 

Prunes. 


100 

1.8 

0.0 

62.0 

260 

260 

Raisins. 


25 

0.57 

0.75 

17.0 

80 

320 

SUGAR 

Granulated. 

sert spoon 

10 

0.0 

0.0 

10.0 

41 

410 

Cubes. 

One 

7 

0.0 

0.0 

7.0 

29 

410 

Dominoes. 

One 

6 

0.0 

0.0 

6.0 

25 

410 

Milk sugar. 

.. .1 level tbsp. 

10 

0.0 

0.0 

10.0 

41 

410 

Honey. 

... 1 tbsp. 

30 

0.12 

0.0 

24.3 

101 

335 

Maple syrup. 

... 1 tbsp. 

30 

0.0 

0.0 

21.4 

88 

293 

Karo syrup. 

1 tbsp. (20 c.c.) 

30 

0.0 

0.0 

23.0 

95 

318 

Fridge. 

... ixlx%" 

28 

0.8 

2.2 

11.0 

70 

250 

Lolly pop. 

... 1%X%" 

27 

0.0 

0.0 

25.0 

102 

380 

Milk chocolate.... 

... 1x2x14" 

10 

0.75 

3.0 

6.5 

58 

580 









































152 


FOOD VALUE TABLES 


FOOD VALUE OF INDIVIDUAL SERVINGS—Continued 







Car- 

Calo- 

Cal. 


Approxi- 


Pro- 


bohy- 

ries in 

per 


mate Weight, 

tein, 

Fat, 

drates, 

Por- 

100 

Foods 

Quantity 

Gm. 

Gm. 

Gm. 

Gm. 

tion 

Gm. 

ICES 








Ice cream. 

.1 hpg. tbsp. 

50 

2.6 

5.0 

9.0 

95 

190 

CAKE 








Chocolate layer_ 


40 

2.48 

3.24 

25.6 

140 

350 

Ginger bread. 

. 2x3x1" 

60 

3.6 

5.4 

38.0 

220 

365 

Lady fingers. 

One 

12 

1.0 

0.6 

8.5 

43 

350 

Sponge. 

. 2x3V 2 xy 2 " 

23 

1.45 

2.5 

15.0 

91 

396 

PIES 








Apple. 

. One sixth 

126 

3.9 

12.35 

54.0 

352 

280 

Custard. 

. One sixth 

133 

5.6 

8.4 

34.7 

243 

183 

Lemon cream. 

. One sixth 

110 

4.0 

11.1 

41.0 

288 

262 

Squash. 

. One sixth 

133 

5.8 

11.1 

28.8 

246 

185 

NUTS 








Almonds. 

. Ten large 

15 

3.1 

8.2 

2.6 

100 

668 

Peanuts. 

.15 (in shell) 

30 

5.8 

8.7 

5.5 

128 

427 

Walnuts, English... 

Ten 

42 

7.7 

27.0 

5.5 

306 

728 

PUDDINGS 








Bread pudding. 

. 1 rounded 

35 

1.8 

1.6 

13.0 

75 

220 

Ingredients: 

tbsp. 







1 cup bread crumbs 







1 cup milk 

1 egg 

V 2 cup sugar 
% cup raisins 








Baked custard. 

. 1 rounded 

45 

2.4 

2.5 

7.0 

61 

135 

Ingredients: 

tbsp. 







2 cups milk 

2 eggs 

14 cup sugar 








Soft custard. 

. 1 rounded 

10 

1.7 

1.1 

2.0 

22 

220 

Ingredients: 

tbsp. 






Yolk 1 egg 
cup milk 

1 h. tbsp. sugar 








Rice custard. 

. 1 rounded 

35 

2.15 

1.7 

8.6 

60 

170 

Ingredients: 

tbsp. 





1 cup boiled rice 

2 eggs 

V/z cups milk 

2 h. tbsp. sugar 








Floating island. 

. 1 rounded 

18 

1.65 

1.7 

3.0 

35 

200 

Ingredients: 

tbsp. 





V 2 tsp. cornstarch 
1 h. tsp. sugar 
l egg 

1 cup milk. 


Comparative approximate measurements: 1 rounded tablespoonful 
equals 1 ounce by volume, cooked vegetables, cereals and meat cut in 
small pieces; 1 heaping tablespoonful equals 1% ounces by volume 
cereals; 2 level tablespoonsful equal 1 ounce by volume, cane sugar. 

























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